Card Range To Study

359 Cards in this Set

Front

Back

3rd side (hint)

A 14-year-old boy is hit over the right side of the head with a baseball bat. He loses consciousness for a few minutes, but recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated.
Dx?
How is it diagnosed?
Tx?

Dx: Acute epidural hematoma (probably right side)

Diagnostic Test: CT scan

Treatment: Emergency surgical decompression (craniotomy)

Good prognosis if treated, fatal within hours if it is not.

None

A 32-year-old male is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride and arrives at the E.R. in deep coma, with a fixed, dilated right pupil.
Dx?
Diagnostic Test?
Tx?

Dx: Acute Subdural hematoma

Diagnostic Test: CT scan
(Also need to check cervical spine!)

Treatment: Emergency craniotomy

poor prognosis because of brain injury

None

A 77-year-old man becomes “senile” over a period of three or four weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began.
Dx?
Diagnostic Test?
Tx?

Dx: Chronic subdural hematoma.

Diagnostic Test: CT scan

Treatment: Surgical decompression (craniotomy)

Spectacular improvement expected

None

A car hits a pedestrian. He arrives in the ER in coma. He has…(raccoon eyes… or clear fluid dripping from the nose…or clear fluid dripping from the ear…or ecchymosis behind the ear)…
Dx?
Diagnostic Test?
Tx?

Dx: Base of the skull fracture.

Diagnostic Test: CT scan and cervical spine X-Rays.

Tx: needs neurosurgical consult and antibiotics

None

A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma, with fixed dilated pupils. He has multiple other injuries (extremities, etc). His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What is the reason for the low BP and high pulse rate?

A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.
Dx?
Management? (3)
Tx?

Dx: Hypovolemic shock

Management: Big bore IV lines, Foley catheter and I.V. antibiotics.

Tx: Ideally Exploratory Lap immediately for control of bleeding, and then fluid and blood administration.

None

A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation.
Dx?
Diagnostic test?
Tx?

Dx: Pericardial tamponade

Diagnostic test: No X-Rays needed, this is a clinical diagnosis!
Do Pericardial window.

Tx: If positive, follow with Thoracotomy, and then Exploratory Lap.

None

A 22-year-old gang member arrives in the E.R. with a single gunshot wound to the precordial area. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation.
Dx?
Management?

A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and abdomen. He has labored breathing is cyanotic, diaphoretic, cold and shivering. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. He is in respiratory distress, has big distended veins in his neck and forehead, his trachea is deviated to the left, and the right side of his chest is tympantic, with no breath sounds.
Dx?
Management? (2 steps)
Tx?

Dx: Tension pneumothorax

Management:
1. Immediate big bore IV catheter placed into the right pleural space (2nd intercostal midclavicular)
2. followed by Chest Tube to the right side, Immediately!

(Watch out for trap that offers chest X-Ray as an option. This is a clinical diagnosis, and patient needs that chest tube now. He will die if sent to X-Ray.)

Tx: Exploratory lap will follow

None

A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history when picked up by the EMT, and on arrival at the ER he is cold and diaphoretic and his blood pressure is 80 over 65. He has an irregular, feeble pulse at a rate of 130. His neck and forehead veins are distended and he is short of breath.
Dx?
Management?

Dx: Cardiogenic shock, from massive MI

Management: verify high CVP. EKG, enzymes, coronary care unit etc. Do not drown him with enthusiastic fluid “resuscitation”, but use thrombolytic therapy if offered

None

A 17 year old girl is stung by a swarm of bees…or a man of whatever age breaks out with hives after a penicillin infection…or a patient undergoing surgery under spinal anesthetic…eventually develop BP of 75 over 25, pulse rate of 150, but they look warm and flushed rather than pale and cold. CVP is low.
Dx?
Management? (2)

Dx: Vasomotor shock
(massive vasodilation, loss of vascular tone)

Management: Vasoconstrictors and Volume replacement as needed

None

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion.
Dx?
Diagnostic Test?
Tx (specific)?

Dx: Plain pneumothorax

Diagnostic Test: There is time to get a chest X-Ray if the option if offered

Treatment: Chest tube to underwater seal and suction, high in the pleural cavity

None

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stale vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion.
Dx?
Diagnostic Test?
Tx?

Dx: Hemothorax

Diagnostic Test: Chest X-Ray

Treatment: Chest tube on the right, at the base of the pleural cavity

None

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood, drains another 20 c in the next hour.
Dx?
Further Tx?

Dx: Hemothorax

Further treatment: The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed.

Key clue: little blood retrieved, even less afterwards

None

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood pressure is 95 over 70, pulse rate of 100. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 1250 cc of blood…(or it could be only 450 cc at the outset, but followed by another 420 cc in the next hour and so on).
Dx?
Further Tx?

Dx: Hemothorax

Further treatment: The rare exception who is bleeding from a systemic vessel (almost invariably intercostal) will need Thoracotomy to ligate the vessel

None

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion at the apex of the right chest, dull at the base. Chest X-Ray shows one single, large air-fluid level.
Dx?
Tx?

Dx: Hemo-pneumothorax

Tx: Chest tube, surgery only if bleeding a lot

None

A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R. gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45. Pulse rate 160, feeble. She has distended neck and forehead veins, is diaphoretic. Left hemithorax has no breath sounds, is tympanic to percussion.
Dx?
Where is the trauma?
Management?

Dx: Tension Pneumothorax

Where is the penetrating trauma? The fractured ribs can act as a penetrating weapon.

Management: Chest Tube to the left immediately!

None

A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales.
Dx?
Next step if she is going to OR?
Next step if not doing well?

Dx: Flail Chest
(paradoxical breathing)

to OR:
prophylactic Bilateral Chest Tubes
(because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic)

not well:
Intubate and give Positive Pressure ventilation
(Flail chest is usually assoc w/ pulmonary contusion, leading to inadequate respiration from pain)

None

A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white out” on X-Rays and she is in respiratory distress.
Dx?
Management? (2 together)

Dx: Pulmonary contusion.

It does not always show up right away, may become evident one or two days after the trauma.

A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a crunching feeling of crepitation elicited by palpation.
Dx?
Further Tests?

Dx: Sternal fracture
(but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta)

A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest X-Ray shows air fluid levels in the left chest.
Dx?
Management?

Dx: Diaphragmatic rupture
(It is always on the left)

Management: Surgical repair

None

A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar’s Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the ER he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum.
Dx?
Diagnostic Test?
Tx?

Dx: traumatic rupture of the aorta

(King size trauma, fracture of a hard-to-break bone...it could be first rib, scapula or sternum...and the tell-tale hint of widened mediastinum)

Diagnostic Test: Arteriogram (aortogram)

Treatment: Emergency surgical repair

None

A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck.
Dx?
Test for additional findings?
Diagnostic test?
Tx?

Dx: Traumatic rupture of the trachea or major bronchus

Additional findings: Chest X-Ray would confirm the presence of air in the tissues

Diagnostic test: Fiberoptic bronchoscopy
(to confirm diagnosis and level of injury and to secure an airway)

Tx: Surgical repair

None

A 26-year-old lady has been involved in a car wreck. She has fractures in upper extremities, facial lacerations and no other obvious injuries. Chest X-Ray is normal. Shortly thereafter she develops hypotension, tachycardia and dropping hematocrit. Her CVP is low.
Dx?
Diagnostic Test if stable?
Unstable? (2 possible)
Tx?

A 19 year old gang member is shot in the abdomen with a 38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender.
Management (specific)?

Management:
A penetrating wound of the abdomen gets exploratory laparotomy every time.

preparations prior to surgery:
an indwelling bladder catheter, a big bore venous line for fluid administration and a dose of broad spectrum antibiotics.

None

A 19 year old gang member is shot once with a 38 caliber revolver. The entry wound is in the left mid-clavicular line, two inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical exam is difficult to do.
Management?

Management:
The point here is to remind you of the boundaries of the abdomen. Although this sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line, though. Belly and chest are not stacked up like pancakes, they are separated by a dome. This fellow needs all the stuff for a penetrating chest wound (chest X-Ray, chest tube if needed), plus the exploratory lap

None

A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128.
Dx?
Diagnostic test if stable?
Diagnostic test if crashing? (2)
Tx?

Dx: Ruptured spleen

Management if Stable: CT Scan
(if he responds promptly to fluid administration, and does not require blood; further management in that case may well be continued observation with serial CT scans)

Management if “crashing”: Peritoneal Lavage or Sonogram followed by (Tx)Exploratory Laparotomy

None

A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128, which do not respond satisfactorily to fluid and blood administration. He has a positive peritoneal lavage and an exploratory laparotomy where a ruptured spleen is found and it is not salvagable.
Further Management?

Further Management:

administration of Pneumovax and some would also Immunize for Hemophilus Influenza B and Meningococcus

None

A 31 year old lady smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 75 over 55, with a pulse rate of 110. On physical exam she has a tender abdomen, with guarding and rebound on all quadrants.
Dx?
Management?

Dx: Blood (and possible feces) in the belly

Management: Exploratory lap

None

A 31 year old lady smashes her car against a wall. Her abdomen is tender with guarding and rebound tenderness present in all quadrants
Dx?
Management?

Dx: Ruptured bowel

Management: Exploratory lap, and repair of the injuries

None

A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. On physical exam there is blood in the meatus.
Dx? (2 possible)
Diagnostic test?

Diagnostic test: Retrograde Urethrogram
(because urethral injury would be compounded by insertion of a Foley catheter)

None

A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus, scrotal hematoma and the sensation that he wants to urinate but can not do it. Rectal exam shows a “high riding prostate”.
Dx?
Diagnostic Test?
Management?

Dx: Posterior Urethral injury.

Diagnostic test: Retrograde Urethrogram

Management:
Suprapubic catheter
(and the repair is delayed 6 months)

None

A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus and scrotal hematoma. Retrograde urethrogram shows an anterior urethral injury.
Management?

Management: Anterior urethral injuries are repaired right away

None

A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter shows that there is gross hematuria.
Dx?
Diagnostic test?

Dx: Bladder injury
(Presumably there was no blood in the meatus to warn against the insertion of an indwelling catheter, and since the latter was accomplished without problem, the urethra must be intact)

Diagnostic test: Retrograde Cystogram

None

A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is gross hematuria, and retrograde cystogram is normal.
Dx?
Diagnostic Test?

Dx: Kidney injury
(Lower injuries have been ruled out)

Diagnostic test: CT scan

(They will not ask you for fine-judgment surgical decisions, but the rule is that traumatic hematuria does not need surgery even if the kidney is smashed.
They operate only if the renal pedicle is avulsed or the patient is exsanguinating)

None

A 35 year old male is about to be discharged from the hospital where he was under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic hematuria.
Management?

Management: Gross traumatic hematuria in the adult always has to be investigated

None

A 4 year old falls from his tricycle. In the ensuing evaluation he is found to have microscopic hematuria.
Management?

Management: Microhematuria in kids needs to be investigated, as it often signifies congenital anomalies…particularly if the magnitude of the trauma does not justify the bleeding.
Start with a Sonogram

None

A 14 year old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes in to the E.R. with a scrotal hematoma the size of a grapefruit.
What should be the physician's concern?
Diagnostic test?
Management?

Concern: The issue in scrotal hematomas is whether the testicle is ruptured or not.

Diagnostic test: Sonogram

Management: If ruptured, surgery will be needed. If intact, only symptomatic treatment

None

A 41 year old male presents to the E.R. reporting that he slipped in the shower and injured his penis. Exam reveals a large penile shaft hematoma with normal appearing glans.
Dx?
Tx?

Dx: Fracture of the tunica albuginea
(including the usual cover story given by the patient. These always happen during sexual intercourse with woman on top)

Tx: this is one of the few urological emergencies.
Surgical repair is needed

None

You get a phone call from a frantic mother. Her 7 year old girl spilled Drano all over her arms and legs. You can hear the girl screaming in pain in the background.
Management?

Management:
The point of this question is that chemical injuries – particularly alkalis-need copious, immediate, profuse irrigation.

Instruct the mother to do so right at home with tap water, for at least 30 minutes before rushing the girl to the E.R

None

While trying to hook up illegally to cable TV, an unfortunate man comes in contact with a high tension electrical power line. He has an entrance burn wound in the upper outer thigh and an exit burn lower down on the same side.
Tx?
What can occur from this event?
Management of this? (3)

A man is rescued by firemen from a burning building. On admission it is noted that he has burns around the mouth and nose, and the inside of his mouth and throat look like the inside of a chimney.
Dx?
Diagnostic Test?
Management?

Dx: Inhalation burns

Diagnostic test: Bronchoscopy

Management: Respiratory support

None

A patient has suffered third degree burns to both of his arms when his shirt caught on fire while lighting the back yard barbecue. The burned areas are dry, white, leatherly anesthetic, and circumferential all around arms and forearms.
What is main problem?
Management? (2)

Problem: Circumferential burns
(The leatherly eschar will not expand, while the are under the burn will develop massive edema, thus circulation will be cut off or in the case of circumferential burns of the chest, breathing will be compromised)

Management: Compulsive monitoring of peripheral pulses and capillary filling.
Escharotomies at the bedside at the first sign of compromised circulation

None

A toddler is brought to the E.R. with burns on both of his buttocks. The areas are moist, have blisters and are exquisitely painful to touch. The story is that the kid accidentally pulled a pot of boiling water over himself.
what type of burn?
What should the physician question?
Management? (2)

Dx: Second degree burn
(Note that in kids third degree is deep bright red, rather than white leatherly as in the adult)

Question: How did it really happen? Burns in kids always bring up the possibility of child abuse, particularly if they have the distribution that you would expect if you grabbed the kid by arms and legs and dunked him in a pot of boiling water.

An adult male who weight “X” Kgs. Sustains second and third degree burns over ---whatever--- The burns will be depicted in a drawing, indicating what is second degree (moist, blisters, painful) and what is third degree (white, leatherly, anesthetic).
What is the equation for proper fluid resuscitation management?
What fluid and how much in first 8 hours?

Management:
4cc per Kg. of body weight per percentage of burned area
(up to 50%)

(if pt is 70kg and 18% burned, then 70x4x18)

Fluid: Ringers Lactate

(half of the calculated dose goes in during first 8 hours)

None

A 42 year old lady drops her hot iron on her lap while doing the laundry. She comes in with the shape of the iron clearly delineated on her upper thigh. The area is white, dry, leatherly, anesthetic.
Tx?

Tx: Early excision and skin grafting
(in very small third degree burns)

None

A 22 year old gang leader comes to the E.R. with a small, 1 cm. deep sharp cut over the knuckle of the right middle finger. He says he cut himself with a screwdriver while fixing his car.
Dx?
Management?

Dx: The description is classical for a human bite. No, nobody actually bit him, he did it by punching someone in the mouth...and getting cut with the teeth that were smashed by his fist. The imaginative cover story usually comes with this kind of lesion.

Management: human bites are bacteriological the dirtiest that one can get. Rabies shots will not be needed, but surgical exploration by an orthopedic surgeon will be required.

None

A 65 year old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2 cm skin mass over the bridge of the nose that has been slowly growing over the past three years. There are no enlarged lymph nodes in the head and neck.
Dx?
Diagnostic Test?
Tx?

Dx: Basal cell carcinoma

Diagnostic test: Full thickness biopsy at the edge of the lesion (punch or knife)

A 71 year old West Texas farmer of Irish ancestry has a non-healing, indolent, punched out, clean looking 2 cm ulcer over the left temple, that has been slowly becoming larger over the past three years. There are no enlarged lymph nodes in the head and neck.
Dx?
Diagnostic Test?
Tx?

Dx: Basal cell carcinoma

Diagnostic Test: Full thickness biopsy at the edge of the lesion (punch or knife)

Tx: Surgical excision with clear margins, but conservative width

None

A blond, blue eyed, 69 year old sailor has a non-healing, indolent 1.5 cm. ulcer on the lower lip, that has been present, and slowly enlarging for the past 8 months. He is a pipe smoker, and he has no other lesions or physical findings.
Dx?
Diagnostic Test?
Tx? (2 possible)

A red headed 23 year old lady who worships the sun, and who happens to be full of freckles, consults you for a skin lesion on her shoulder that concerns her. She has a pigmented lesion that is asymmetrical, with irregular borders, of different colors within the lesion, and measuring 1.8 cms
Dx?
Diagnostic Test?

Dx: Melanoma or Dysplastic Nevus

Diagnostic test: full thickness biopsy at the edge of the lesion

- margin free local excision if superficial melanoma
(Clarks’ levels one or two, or under 0.75 mm)
- wide local excision with 2 or 3 cm margin if deep melanoma

None

A 35 year old blond, blue eyed man left his native Minnesota at age 18, and has been living the life as a crew member for a sailing yacht charter operation in the Caribbean. He has multiple nevi all over his body, but one of them has changed recently.
Dx?
Management?

Dx: Melanoma

(Change in a pigmented lesion is the other tip off to melanoma...It may be growth, or bleeding, or ulceration, or change in color)

Management: Full-thickness biopsy at the edge of the lesion

- margin free local excision if superficial melanoma
(Clarks’ levels one or two, or under 0.75 mm)
- wide local excision with 2 or 3 cm margin if deep

None

A 44 year old man has unequivocal signs of multiple liver metastasis, but no primary tumor has been identified by multiple diagnostic studies of the abdomen and chest. The only abnormality in the physical exam is a missing toe, which he says was removed at the age of 18 for a black tumor under the toenail.
Dx?
Diagnostic Test for initial problem?

Dx: Malignant Melanoma

(the alternate version has a glass eye, and history of enucleation for a tumor. No self-respecting malignant tumor would have this time interval, but melanoma will)

Diagnostic Test: full thickness biopsy at the edge of the lesion

- margin free local excision if superficial melanoma
(Clarks’ levels one or two, or under 0.75 mm)
- wide local excision with 2 or 3 cm. margin if deep melanoma

None

A 32 year old gentleman had a Clark’s level 5, 3.4 mm. Deep, melanoma removed from the middle of his back three years ago. He now has…(a tumor in a weird place, like his left ventricle, his duodenum, his ischiorectal area...anywhere!)
Dx?

Dx: Melanoma

(The point of this vignette is that invasive melanoma...it has to be deep...metastasizes to all the usual places [lymph nodes plus liver-lung-brain-bone] but it is also the all-time-champion in going to weird places where few other tumors dare to go)

None

An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation.
Dx?
Diagnostic Test?
Imaging technique for young patient?

(The only safe answer, even if the presentation favors benign disease, is to get tissue diagnosis)

Sonogram is the only imaging technique suitable for the very young breast

None

A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to its present size. The mass is firm, rubbery, completely movable, is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.
Dx?
Diagnostic Test?

Dx: Cystosarcoma Phyllodes

(basically same presentation as Fibroadenoma, but >25yo)

Diagnostic test: given the size best done with core or incisional biopsy

(no need for axillary node dissection w/ phyllodes...mets is rare)

None

A 35 year old lady has a ten year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to “come and go” at different times in the menstrual cycle. Now has a firm, round, 2 cm. mass that has not gone away for 6 weeks.
Dx?
Diagnostic Test?

Dx: Fibrocystic disease

Diagnostic test: Aspiration of the Cyst

(tissue diagnosis [i.e: biopsy] becomes impractical when there are lumps every month)

If the mass goes away and the fluid aspirated is clear, that’s all.
If the fluid is bloody it goes to cytology.
If the mass does not go away, or recurs she needs biopsy.
(Answers that offer mammogram or sonogram in addition to the aspiration would be OK, but not as the only choice)

None

A 34 year old lady has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses.
Dx?
Diagnostic Test?
if test is inconclusive?

Dx: Intraductal papilloma

Diagnostic test: Mammogram
(the way to detect breast cancer that is not palpable)

(If negative, one may still wish to find an resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or done as a retroareolar exploration)

None

A 26 year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis.
Dx?
Management?

Dx: Abscess

(However, only lactating breasts are “entitled” to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise.)

Management: Incision and Drainage

(if an option includes drainage with biopsy of the abscess wall, go for that one)

None

A 49 year old has a firm 2cm mass in the right breast that has been present for 3 months.
Dx?
Management?

Dx: This could be anything.

(Age is the best determinant for Cancer of the breast. If she had been 72, you go for cancer. At 22, you favor benign. But they will not ask you what this is, they will ask what do you do.)

Management: You have to have tissue. Core biopsy is OK, but if negative you don’t stop there. Only excisional biopsy will rule out cancer

None

A 69 year old lady has a 4 cm hard mass in the right breast, with ill defined borders, movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted an has an “orange peel” appearance…or the nipple became retracted six months ago.
Dx?
Diagnostic Test?

Dx: Cancer of the Breast

Diagnostic test: Core or Excisional Bx

None

A 62 year old lady has an eczematoid lesion in the areola. It has been present for 3 months and it looks to her like “some kind of skin condition” that has not improved or gone away with a variety of lotions and ointments
Dx?
Diagnostic Test?

Dx: Paget’s disease of the breast
(which is a cancer under the areola)

Management: Full thickness punch biopsy of the skin would be OK, but core biopsy or incisional biopsy of the tissue underneath would be OK also

None

A 42 year old lady hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and one week later the lump is still there. She has a 3 cm hard mass deep inside the affected breast, and some superficial ecchymosis over the area
Dx?

Dx: Cancer, until proven otherwise

(A classical trap for the unwary. Trauma often brings the area to the attention of the patient...but is not cause of the lump.)

None

A 58 year old lady discovers a mass in her right axilla. She has a discreet, hard, movable, 2cm mass. Examination of her breast is negative, and she has not enlarged lymph nodes elsewhere
Dx?
Diagnostic Test? (2)

Dx: Cancer, until proven otherwise

(A tough one, but another potential presentation for cancer of the breast. In a younger patient you would think lymphoma. It could still be lymphoma on her.)

A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present two year ago on a previous mammogram
Dx?
Further Management?

Dx: Cancer of the Breast

Further management: Stereotactic Radiologically guided Core Biopsy

(If unsatisfactory, the next move would be needle localized excisional biopsy)

None

A 44 year old lady has a 2cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal carcinoma. The mass is freely movable and her breast is of normal, rather generous size. She has no palpable axillary nodes

Axillary node dissection is to help determine the need for adjuvant systemic therapy

None

A 62 year old lady has a 4 cm hard mass under the nipple and areola of her rather smallish left breast. A core biopsy has established a diagnosis of infiltrating ductal carcinoma. There are no palpable axillary nodes.

Management?

Management: Modified Radical Mastectomy

(A Lumpectomy is an option only when the tumor is small [in absolute terms and in relation to the breast] and located where most of the breast can be spared.) A modified radical mastectomy is the choice here.

Why go after the axillary nodes when they are not palpable?: Because palpation is notoriously inaccurate in determining the presence or absence of axillary metastasis.

None

A 44 year old lady shows up in the Emergency Room because she is “bleeding from the breast”. Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly attached to the chest wall. The patient maintains that the mass has been present for only “a few weeks”, but a relative indicates that it has been there at least two years, maybe longer.
Dx?
Diagnostic Test?
Management?

Dx: Advanced Cancer of the Breast

Diagnostic Test: Core or an Incisional biopsy

Management: currently inoperable, and incurable as well...but palliation can be offered.
Chemotherapy is the first line of treatment.
(In many cases the tumor will shrink enough to become operable)

None

A 37 year old lady has a lumpectomy and axillary dissection for a 3cm infiltrating ductal carcinoma. The pathologist reports clear surgical margins and metastatic cancer in 4 out of 17 axillary nodes.

Management?

Management: Chemotherapy

(Only very small tumors with negative nodes and very favorable histological pattern are “cured” with surgery alone. More extensive tumors need adjuvant systemic therapy, and the rule is that premenopausal women get chemotherapy and postmenopausal women get hormonal therapy.)

None

A 66 year old lady has a modified radical mastectomy for infiltrating ductal carcinoma of the breast. The pathologist reports that tumor measures 4 cm. in diameter and that 7 out of 22 axillary node are positive for metastasis. The tumor is estrogen and progesterone receptor positive.

Management?

Management: Hormonal therapy

(The agent used is Tamoxifen)

None

A 44 year old lady complains bitterly of severe headaches that have been present for several weeks and have not responded to the usual over-the-counter headache remedies. She is two years post-op. from modified radical mastectomy for T3, N2, M0 cancer of the breast, and she had several courses of post-op chemotherapy which she eventually discontinued because of the side effects.
Dx?
Diagnostic Test?

Dx: Brain mets (until proven otherwise)

(Don’t get hung up on the TNM classification, if the numbers are not 1 for the tumor and zero for the nodes and mets, the tumor is bad.)

Diagnostic Test: CT scan of the brain

None

A 39 year old lady completed her last course of postoperative adjuvant chemotherapy for breast cancer six months ago. She comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well circumscribed areas in the thoracic and lumbar spine.
Dx?
Diagnostic Test?

Dx: Bone mets until proven otherwise

Diagnostic test: Bone Scan
(the most sensitive test for bone mets)

If positive, X-Rays are needed to rule out benign reasons for the scan to “light up”.

None

A young mother is visiting your office for routine medical care. She happens to have her 18 month old baby with her, and you happen to notice that one of the pupils of the baby is white, while the other one is black.
Dx Differential? (2)

Dx Diff: Retinoblastoma or Cataracts

(An ophthalmological and potentially life-and-death emergency. A white pupil (leukocoria) at this age can be retinoblastoma. This kid needs to see the ophthalmologist not next week, but today or tomorrow. If it turns out to be something more innocent, like a cataract, the kid still needs it corrected to avoid amblyopia.)

None

Your distant cousins that you have not seen for years visit you and brag about their beautiful baby with “huge, shiny eyes”. They show you a picture that indeed proves their assertion (or the exam booklet will have such a picture).
Dx?

Dx: Huge eyes in babies can be Congenital Glaucoma.

(Tearing will indeed make them shine all the time. If undiagnosed, blindness will ensue.)

None

A 53 year old lady is in the ER complaining of extremely severe frontal headache. The pain started about one hour ago, shortly after she left the movies where she watched a double feature. On further questioning, she reports seeing halos around the lights in the parking lot when leaving the theater. On physical exam the pupils are mid-dilated, do not react to light, the corneas are cloudy and with a greenish hue, and the eyes feel “hard as a rock”.
Dx?
Management?
Medicine Tx? (3 possible)

Dx: Acute glaucoma

(most are asymptomatic)

Management: An ophthalmologist is needed stat

Tx:
1. Diamox
2. Pilocarpine drops
3. Mannitol

None

A 32 year old lady presents in the E.R. with swollen, red, hot, tender eyelids on the left eye. She has fever and leukocytosis. When prying the eyelids open, you can ascertain that her pupil is dilated and fixed and that she has very limited motion of that left eye.
Dx?
Management?
Tx?

Dx: Orbital Cellulitis

Management: CT scan

(Ophthalmological emergency that requires immediate consultation)

Tx: Surgical drainage

None

A frantic mother reaches you on the phone, reporting that her 10 year old boy accidentally splashed Drano on his face and is screaming in pain complaining that his right eye hurts terribly.
Management?

Management: The key is immediate irrigation. Instruct the mother to pry the eye open under the cold water tap at home, and irrigate for about ½ hour before she brings the kid to the hospital.

None

A 59 year old, myopic gentleman reports “seeing flashes of light” at night, when his eyes are closed. Further questioning reveals that he also sees “floaters” during the day, that they number ten or twenty, and that he also sees a cloud at the top of his visual field.
Dx?
Management and Tx?

Dx: Retinal Detachment

(that “cloud” at the top of the visual field is hemorrhage settling at the bottom of the eye)

Management: Another Ophthalmological emergency. The retina specialist will use Laser treatment to “spot weld” the retina back in place

None

A 77 year old man suddenly loses sight from the right eye. He calls you on the phone 10 minutes after the onset of the problem. He reports no other neurological symptoms.
Dx?
Management?

Dx: Embolic occlusion of the retinal artery

Management: Another ophthalmological emergency...although little can be done for the problem.
He has to get the ER instantly and it might help for him to breathe into a paper bag on route, and have someone press hard on his eye and release repeatedly

None

A 55 year old man is diagnosed with type two diabetes mellitus. On questioning about eye symptoms he reports that sometimes after a heavy dinner the television becomes blurry and he has to squint to see it clearly.
Dx?
Management?

Dx: Simply DM-related changes in eye

(no big deal: the lens swells and shrinks in response to swings in blood sugar)

A 54 year old obese man gives a history of burning retrosternal pain and “heartburn” that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems to be progressing since it started several years ago.
Dx?
Management?

Dx: Gastroesophageal reflux

Management: Endoscopy and biopsies

(to assess the extent of esophagitis and potential complications before medication)

None

A 54 year old obese man gives a history of burning retrosternal pain and “heartburn” that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems to be progressing since it started several years ago. Endoscopy shows severe peptic esophagitis and Barrett’s esophagus.
Management?

Management: Nissen Fundoplication

(since Barrett’s is premalignant)

None

A 62 year old man describes severe epigastric and substernal pain that he can not characterize well. There is a history suggestive of gastroesophageal reflux, and EKG and cardiac enzymes have been repeatedly negative.
Diagnostic test?

Diagnostic test: Acid Perfusion (Bernstein) test

(it reproduces the pain when the lower esophagus is irrigated with an acid solution to tell if it is only GERD)

None

A 44 year old black man describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to soft foods and is now evident for liquids as well. He locates the place where food “sticks” at the lower end of the sternum. He has lost 30 pounds of weight.
Dx?
Diagnostic tests? (3 in order)

A 47 year old lady describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to “make it through”. Occasionally she regurgitates large amounts of undigested food.
Dx?
Diagnostic test? (3)
Tx? (3 possible)

A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood.
Dx?
Diagnostic test?

Dx: Mallory Weiss tear

Diagnostic test: Endoscopy

(Photocoagulation may be used if needed)

None

A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting and he feels a very severe, wrenching epigastric and low sternal pain of sudden onset. On arrival at the E.R. one hour later he still has the pain, he is diaphoretic, has fever and leukocytosis and looks quite ill.
Dx?
Diagnostic test?
Tx?

Dx: Boerhave’s syndrome

Diagnostic test: Gastrographin swallow

Treatment: Emergency surgical repair

(Prognosis depends on time elapsed between perforation and treatment)

None

A 55 year old man has an upper G.I. endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant, retrosternal pain that began shortly after he went home. He looks prostrate, very ill, is diaphoretic, has a temperature of 104 and respiratory rate of 30.
Dx?
Diagnostic test?

Dx: Instrumental perforation of the esophagus

Diagnostic test: Gastrographin swallow

None

A 72 year old man has lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.
Dx?
Diagnostic test?

Diagnostic test: Chest or Abdominal x-ray to show free air under diaphragm

None

A 52 year old woman presents due to 3 months of early satiety, weight loss and non-bilious vomiting.
Dx?

Dx: Gastric Outlet Obstruction

None

A 55 year old patient w/ known PUD presents w/ sudden onset of severe epigastric pain that radiates to the back. Physical exam reveals guarding and rebound tenderness. An Abdominal x-ray does not show free air under diaphragm.
Dx?

Dx: Posterior Perforated ulcer

(An Abdominal x-ray will not show free air under diaphragm if it is a posterior perforation)

None

A 45 year old Japanese male smoker presents with weight loss and epigastric pain exacerbated by eating.
Dx?
Diagnostic test?

Dx: Gastric Ulcer

Diagnostic test: Endoscopy w/ Bx

None

A 24 year old patient who was recently a burn victim over 36% of his body presents with epigastric pain exacerbated by eating.
Dx?

Dx: Curling’s Ulcers

(Gastric stress ulcers w/ severe burns. “Burnt paper CURLS”)

None

A 72 year old recent stroke patient begins to have severe epigastric pain that is exacerbated by eating.
Dx?

Dx: Cushing’s Ulcers

(Gastric ulcer related to severe CNS damage)

None

A 58 year old woman who is 6 days post-op from a gastrojejunostomy for PUD presents w/ postprandial RUQ pain and nausea. She reports that vomiting relieves her suffering.
Dx?
Diagnostic test?
Tx?

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen.
Dx?
Management?

Dx: Mechanical Intestinal Obstruction, due to adhesions

Management: Nasogastric suction, I.V. fluids and careful observation

None

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched loud bowel sounds that coincide with the colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on nasogastric suction and I.V. fluids, he develops fever, leukocytosis, abdominal tenderness and rebound tenderness
Dx?
Management?

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. On physical exam a groin mass is noted, and he explains that he used to be able to “push it back” at will, but for the past 5 days has been unable to do so.
Dx?
Management?

A 55 year old lady is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent jugular venous pulse is noted on her neck.
Dx?
Diagnostic test? (2 steps)
Tx? (3 depending on position)

A 22 year old man develops vague periumbilical pain that several hours later becomes sharp, severe, constant and well localized to the right lower quadrant of the abdomen. On physical examination he has abdominal tenderness, guarding and rebound to the right and below the umbilicus. He has a temperature of 99.6 and a WBC of 12,500, with neutrophilia and immature forms.
Dx?
Management?

Dx: Acute Appendicitis

Management: Exploratory laparotomy and appendectomy

None

A 70 year old male with a history of peripheral vascular disease and hyperlipidemia presents to the ER with diffuse abdominal pain. His BP is 170/100 and his pulse is 90bpm. Supine abdominal radiographs shows air in the wall of the small intestine.
Dx?

Dx: Small bowel Infarction

None

A patient presents with pigmented spots on his lips and a history of recurrent colicky abdominal pain.
Dx?

Dx: Peutz-Jeghers syndrome

None

A 5 year old child presents with increasing irritability, colicky abdominal pain and rectal bleeding w/ stools that have a currant jelly appearance. A mass is palpated in the right lower quadrant.
Dx?
Diagnostic test? (2)

A 59 year old is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only 4+ occult blood in the stool. Lab studies show a hemogoblin of 5.
Dx?
Diagnostic test?
Tx?

Dx: Cancer of the right colon

Diagnostic test: Colonoscopy and biopsies

Treatment: Blood transfusions and eventually Right Hemicolectomy

None

A 56 year old man has bloody bowel movements. The blood coats the outside of the stool, and has been constipated, and his stools have become of narrow caliber.
Dx?
Diagnostic test?

Dx: Cancer of the distal, left side of the colon

Diagnostic test: Endoscopy and biopsies

(If given choices start with Flexible Sigmoidoscopy)

None

A 42 year old man has suffered from chronic ulcerative colitis for 20 years. He weights 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Due to a recent relapse, he has been placed on high dose steroids and immuran. For the past 12 hours he has had severe abdominal pain, temperature of 104 and leukocytosis. He looks ill, and “toxic”. His abdomen is tender particularly in the epigastric area, and he has muscle guarding and rebound. X-Rays show a massively distended transverse colon, and there is gas within the wall of the colon.
Dx?
Management?

Dx: Toxic megacolon

Management: Emergency surgery for the toxic megacolon and removal of the rectum

(but the case illustrates many other indications for surgery: chronic malnutrition, “intractability” and risk of developing cancer)

None

A 27 year man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and tobramycin for seven days. Eight hours ago he developed watery diarrhea, crampy abdominal pain fever and leukocytosis
Dx?
Diagnostic test?
Management?

Dx: Pseudomembranous colitis from overgrowth of Clostridium Difficile

Diagnostic test: Stool cultures (but proctosigmoidoscopy can show a typical picture before the cultures are back)

Management: Stop the clindamycin, give either Vancomycin or Metronidazole, and avoid lomotil

None

A 60 year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation.
Dx?
Management?

Dx: Internal hemorrhoids

Management: Proctosigmoidoscopic Examination
(It is not reassurance and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has to be ruled out)

None

A 60 year old man known to have hemorrhoids complains of anal itching and discomfort, particularly towards the end of the day. He has perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort. He is afebrile.
Dx?
Management?

Dx: External hemorrhoids

Management: Proctosigmoidoscopic Examination

(It is not reassurance and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has to be ruled out)

None

A 23 year old lady describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination can not be done, as she refuses to allow anyone to even “spread her cheeks” to look at the anus for fear of precipitating the pain.
Dx?
Management?
Surgical Tx?

Dx: Anal Fissure

Management: Exam under Anesthesia

(Even though the clinical picture is classical, cancer still has to be ruled out)

Tx: Lateral Internal Sphincterotomy

None

A 28 year old male is brought to the office by his mother. Beginning four months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, but actually the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures all around the anus, with purulent discharge. There are no palpable masses.
Dx?
Diagnostic test?
Top 3 medical Tx?

Dx: Crohn's Disease

(The perianal area has fantastic blood supply and heals beautifully even though feces bathe the wounds. When it does not, you immediately think of Crohn’s disease)

Diagnostic test: Flexible sigmoidoscopy with Biopsy
(You still have to rule out malignancy)

Top 3 medical Tx:
1. Sulfasalazine
2. Metronidazole
3. Prednisone

None

A 44 year old man shows up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements are very painful, and that he has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant mass between the anus and the ischial tuberosity.
Dx?
Management?

Dx Ischiorectal abscess

Management: Exam under Anesthesia with Incision and Drainage

(The treatment for all abscesses is drainage. This one is no exception. But as always, cancer has to be ruled out)

None

A 62 year old man complains of perianal discomfort, and reports that there are streaks of fecal soiling in his underwear. Four months ago he had a perirectal abscess drained surgically. Physical exam shows a perianal opening in the skin, and a cord-liked tract can be palpated going from the opening towards the inside of the anal canal. Brownish purulent discharge can be expressed from the tract.
Dx?
First step?
Tx?

Dx: Anal Fistula

First:
Rule-out cancer with Proctosigmoidoscopy

Tx: elective Fistulotomy

None

A 55-year old, HIV positive man, has a fungating mass growing out of the anus, and rock hard, enlarged lymph nodes on both groins. He has lost a lot of weight, and looks emaciated and ill.
Dx?
Diagnostic Test?
Eventual Tx?

A 33 year old man vomits a large amount of bright red blood.
Where can the bleeding be from?
Diagnostic test?

Bleeding from: Tip of the nose to the ligament of Treitz.

Diagnostic test: for all upper G.I. bleeding, start with Endoscopy

None

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110.
Where is bleeding from?
Management?

Bleeding from? Anywhere in GI tract

(The point of the vignette is that something needs to be done to define the area from which he is bleeding. With the available information it could be from anywhere in the G.I. tract)

Management: The first diagnostic move here is to place a Nasogastric tube

None

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns copious amounts of bright red blood.
Management?

Management: Endoscopy

(Same as if he had been vomiting blood)

None

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns clear, green fluid without blood.
Diagnostic test?

Diagnostic test: Angiogram

(Clear fluid, without bile, would have exonerated the area down to the pylorus, and if there is bile in the aspirate, down to the ligament of Treitz...provided you are sure that the patient is bleeding now. That’s the case here. So, he is bleeding from somewhere distal to the ligament of Treitz. Further definition of the actual site is no longer within reach of upper endoscopy, and lower endoscopy is notoriously difficult and unrewarding in massive bleeding. If he is bleeding at more than 2 cc. per minute, emergency angiogram is the way to go)

None

A 72 year old man had three large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood.
Diagnostic test? (2)

Diagnostic test: Upper and Lower Endoscopies

(The clear aspirate is meaningless because he is not bleeding right now. So the guilty territory can be anywhere from the tip of the nose to the anal canal. Across the board, ¾ of all GI bleeding is upper, and virtually all the causes of lower GI bleeding are diseases of the old: diverticulosis, polyps, cancer and angiodysplasias. So, is old, the overall preponderance of upper is balanced by the concentration of lower causes in old people...so it could be anywhere)

None

A 7 year old boy passes a large bloody bowel movement.
Dx?
Diagnostic test?

Dx: Meckel’s diverticulum
(in this age group)

Diagnostic test: Radioactively labeled Technetium scan
(not the one that tags reds cells, but the one that identifies gastric mucosa)

None

A 41 year old man has been in the intensive care unit for two weeks, being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood.
Dx?
Diagnostic test?
How could it have been prevented?
Tx?

Tx: Stress Ulcer

Diagnostic test: Endoscopy

It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antiacids or both

Treatment: Angiographic Embolization of the left gastric artery.

None

A 59 year old man arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal pain that began about one hour ago, and is now generalized, constant and extremely severe. He lies motionless in the stretcher, is diaphoretic and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants.
Dx?
Management?

Dx: Acute Peritonitis (Acute Abdomen)

Management: Emergency Exploratory Laparotomy

None

A 62 year old man with cirrhosis of the liver and ascites, presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis.
Dx?
Diagnostic test?
Tx?

Dx: Primary Peritonitis

(Peritonitis in the cirrhotic with ascitis, or the child with nephrosis and ascitis, could be primary peritonitis – which does not need surgery!)

Diagnostic test: Paracentesis with Cultures of the ascitic fluid will yield a single organism

Treatment: Antibiotics

None

A 43 year old man develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a rigid abdomen, lies motionless in the examining table, has no bowel sounds and is obviously in great pain, which he describes as constant. X-Ray shows free air under the diaphragms.
Dx?
Management?

A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization.
Dx?
Diagnostic test?
If Dx is unclear?
Management? (3 together)

Dx: Acute pancreatitis

Diagnostic test: Serum and Urinary Amylase and Lipase

If unclear: CT scan
(or in a day or two if there is no improvement)

Management: NPO, NG suction, IV fluids.

None

A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.
Dx?
Diagnostic test?
Management?

Dx: Acute cholecystitis

Diagnostic test: Ultrasound

(If equivocal, an “HIDA” scan: radionuclide excretion scan)

Management: “cool down” the process

Surgery will follow

None

A 52 year old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria.
Dx?
Diagnostic test? (2)

Dx: Ureteral colic

Diagnostic test: Urological evaluation always begins with a Plain Film of the abdomen (a “KUB”)

Ultrasound often is the next step
(but traditionally it has been intravenous pyelogram)

None

A 59 year old lady has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis.
Dx?
Diagnostic test?
Management?

Dx: Acute diverticulitis

Diagnostic test: CT scan
(Colonoscopy is not safe in acute setting)

Management: Elective Sigmoid resection
(for recurrent attacks, like this case or if she does not respond to medical Tx from initial attack or gets worse)

(Treatment is medical for the acute attack: antibiotics, NPO)

None

An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers towards the left lower quadrant with the shape of a parrot’s beak.
Dx?
Management?

Dx: Volvulus of the sigmoid

Management: Proctosigmoidoscopy should relieve the obstruction

(Rectal tube is another option. Eventually surgery to prevent recurrences could be considered)

None

A 79 year old man with atrial fibrillation develops and acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-Rays show distended small bowel and distended colon up to the middle of the transverse colon.
Dx?
Tx if mild, moderate or severe?

Dx: Emboli of Mesenteric vessels

(Acute abdomen present in the elderly who has atrial fibrillation, brings to mind embolic occlusion of the mesenteric vessels. Acidosis frequently ensues, and blood in the stool is often seen)

A 53 year old man with cirrhosis of the liver develops malaise, vague right upper quadrant abdominal discomfort and 20 pound weight loss. Physical exam shows a palpable mass that seems to arise from the left lobe of the liver. Alpha feto protein is significantly elevated.
Dx?
Diagnostic test?
Tx?

Dx: Liver cell carcinoma

Diagnostic test: CT scan

Tx: If confined to one lobe, Resection.

None

A 53 year old man develops vague right upper quadrant abdominal discomfort and a 20 pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a right hemicolectomy for cancer of the ascending colon. His carcinoembryogenic antigen (CEA) had been within normal limits right after his hemicolectomy, is now ten times normal.
Dx?
Diagnostic test?
Tx?

Dx: Metastasis to the liver from colon cancer

Diagnostic test: CT scan

Tx: If mets are confined to one lobe: Resection.

(Otherwise, Chemotherapy if he has not had it)

None

A 24 year old lady develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER she is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a hemogoblin of 7. There is no history of trauma. On inquiring as to whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never misses taking them.
Dx?
Management?
Tx?

Dx: Bleeding from a ruptured Hepatic Adenoma, secondary to birth control pills.

A 44 year old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and leukocytosis and some tenderness in the right upper quadrant. An ultrasound reveals a liver mass.
Dx?
Management?

Dx: Pyogenic abscess

Management: it needs to be drained (the radiologists will do it percutaneously)

None

A 29 year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alkaline phosphatase. Ultrasound of the right upper abdominal area shows a normal biliary tree, and an abscess in the liver.
Dx?
Management?

Dx: Amebic abscess
(very common in Mexico)

Management: Serology for Amebic titers and start on Metronidazole
(This one Abscess that does not have to be drained. Get serology for amebic titers, and start the patient on Metranidazole. Prompt improvement will tell you that you are on the right track...serologies in 3 weeks will confirm. Don’t fall for an option that suggests aspirating the pus and sending it for culture, you can not grow the ameba from the pus)

None

A 42 year old lady is jaundiced. She has a total bilirubin of 6 and the laboratory reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is zero. She has no bile in the urine.
Dx?
Management?

Dx: Hemolytic Jaundice

Management: Try to figure out what is chewing her red cells.

None

A 19 year old college student returns from a trip to Cancun, and two weeks later develops malaise, weakness and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alkaline phosphatase is mildly elevated, while the SGOT and SGPT (transaminases) are very high.
Dx?
Management?

Dx: Hepatocellular jaundice

Management: Get serologies to confirm diagnosis and type of Hepatitis

None

A patient with progressive jaundice which has been present for four weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase was twice normal value couple of weeks ago, and now is about six times the upper limit of normal.
Dx?
Management?

Dx: Obstructive jaundice

Diagnostic test? Ultrasound

(looking for dilated intrahepatic ducts, possibly dilated extrahepatic ducts as well, and if we get lucky a finding of gallstones)

None

A 40 year old, obese mother of five children presents with progressive jaundice which she first noticed four weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. She gives a history of multiple episodes of colicky right upper quadrant abdominal pain, brought about by ingestion of fatty food.
Dx?
Diagnostic test? (2)
Tx?

Dx: Obstructive jaundice

Diagnostic test: Ultrasound
(If you need more tests after that, ERCP is the next move, which could also be used to remove the stones from the common duct)

Tx: Cholecystectomy

None

A 66 year old man presents with progressive jaundice which he first noticed six week ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He has lost 10 pounds over the past two months, but is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder.
Dx?
Management? (2)

Dx: Malignant obstructive jaundice.
(“Silent” obstructive jaundice is more likely to be due to tumor. A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder is thick-walled, non-pliable)

Management: CAT scan and ERCP

None

A 66 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal pancreatic duct.
Dx?
Next step?
Tx?

Dx: Malignant, but lucky... probably Cholangiocarcinoma at the lower end of the common duct.

Next step: get brushings of the common duct for cytological diagnosis.

Tx: He could be cured with a pancreatoduodenectomy
(Whipple operation)

None

A 64 year old lady presents with progressive jaundice which she first noticed two weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated SGOT. The alkaline phosphatase is about ten times the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and very distended, thin walled gallbladder.
Dx?
Diagnostic test?
Tx?

Dx: Malignant Obstructive jaundice
(The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an Ampullary carcinoma, another malignancy that can be cured with Radical surgery)

Diagnostic test: Endoscopy

None

A 56 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. He alkaline phosphatase is about eight times the upper limit of normal. He has lost 20 pounds over the past two months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder.
Dx?
Diagnostic test? (2)

Dx: Cancer of the head of the pancreas
(Terrible prognosis)

Diagnostic test: CAT scan –which may show the mass in the head of the pancreas;
then ERCP –which will probably show obstruction of both common duct and pancreatic duct

None

A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestion of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. Physical exam is unremarkable.
Dx?
Diagnostic test?

Dx: Gallstones, with biliary colic

Diagnostic test: Ultrasound

Tx: Elective cholecystectomy

None

A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began three days ago. The pain was colicky at first, but has been constant for the past two and a half days. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. She has temperature spikes to 104 and 105, with chills. Her WBC is
22,000, with a shift to the left. Her bilirubin is 5 and she has an alkaline phosphatase of 2,000 (about 20 times normal). She has had episodes of colicky pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.
Dx?
Further test?
Management? (2)

Dx: Acute Ascending Cholangitis

Further test:
Ultrasound might confirm dilated ducts.

Management:
Emergency decompression of the biliary tract...
ERCP is the first choice, but PTC
(percutaneous transhepatic cholangiogram) is another option

None

A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestions of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain, and the pain lasted longer than usual. She has mild tenderness to palpation in the epigastrium and right upper quadrant. Laboratory determinations show a bilirubin of 3.5, an alkaline phosphatase 5 times normal and a serum amylase 3 times normal value.
Dx?
Diagnostic test?
Management/Tx if she gets better?
If she gets worse?

Dx: She passed a common duct stone and had a transient episode of Cholangitis (the shaking chill, the high phosphatase) and a bit of Biliary Pancreatitis (the high amylase).

Diagnostic test: Ultrasound (It will confirm the diagnosis of gallstones)

Management: If she continues to get well, elective Cholecystectomy.
If she deteriorates, she may have the stone still impacted at the Ampulla of Vater, and may need ERCP and sphincterotomy to extract it

None

A 33 year old, alcoholic male, shows up in the E.R. with epigastric and mid-abdominal pain that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant, very severe, and it radiates straight through to the back. He vomited twice early on, but since then has continued to have retching. He has tenderness and some muscle guarding in the upper abdomen, is afebrile and has mild tachycardia. Serum amylase is 1200, and his hematocrit is 52.
Dx?
Management? (3)

Dx: Acute edematous pancreatitis.

Management: put the pancreas at rest...NPO, NG suction, IV fluids

None

A 56 year old alcoholic male is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight through to the back, and is extremely severe. He has a serum amylase of 800, WBC of 18,000 blood glucose of 150, serum calcium of 6.5 and a hematocrit of 40. He is given IV fluids and kept NPO with NG suction. By the next morning, his hematocrit has dropped to 30 the serum calcium has remained below 7 in spite of calcium administration, his BUN has gone up to 32 and he has developed metabolic acidosis and a low arterial PO2.
Dx?
Management/test?

Dx: Hemorrhagic Pancreatitis
(In fact, he is in deep trouble, with at least eight of Ranson’s criteria predicting 80 to 100% mortality)

Management/test: Very intensive support will be needed, but the common pathway to death from complication of hemorrhagic pancreatitis frequently is by way of pancreatic abscesses that need to be drained as soon as they appear. Thus serial CT scans will be required.

None

A 57 year old alcoholic male is being treated for acute hemorrhagic pancreatis. He was in the intensive care unit for one week, required chest tubes for pleural effusion, and was on a respirator for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease he begins to spike fever and to demonstrate leukocytosis.
Dx?
Diagnostic test?
Tx?

Dx: Pancreatic abscess

Diagnostic test: CT scan

Tx: Drainage

None

A 49 year old alcoholic male presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen, and actually hard to define. He was discharged from the hospital 5 weeks ago, after successful treatment for acute pancreatitis.
Dx?
Diagnostic test?
Tx?

Dx: Pancreatic pseudocyst

Diagnostic test: You could diagnose it on the cheap with an ultrasound, but CT scan is probably the best choice.

Tx: It will need to be drained, and the radiologist will do it with CT guidance

None

A 55 year old lady presents with vague upper abdominal discomfort, early satiety and a large but ill-defined epigastric mass. Five weeks ago she was involved in an automobile accident where she hit the upper abdomen against the steering wheel.
Dx?
Diagnostic test?

Dx: Pancreatic pseudocyst, secondary to trauma

Diagnostic test: CT scan

None

A disheveled, malnourished individual shows up in the emergency room requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back that he says he has had for several years. He has diabetes, steatorrhea and calcifications in the upper abdomen in a plain X-Ray.
Dx?
Diagnostic test?
Management? (3)

Dx: Chronic pancreatitis

Diagnostic test: AXR visualizing calcifications

Management: Stop alcohol, replacement of pancreatic enzymes and control of the diabetes; ERCP

None

On the first post-operative day after an open cholecystectomy, a patient has a temperature of 101.
Dx?
Diagnostic test?
Management? (2 together)

On the third post-operative day after an open cholecystectomy, a patient develops a temperature of 101.
Dx?
Diagnostic test?
Tx?

Urinary tract infection

Diagnostic Test: Urinalysis and Urinary culture

Tx: appropriate Antibiotics

None

On the fourth post-operative day after an open cholecystectomy, a patient develops a temperature of 101. There is tenderness to deep palpation in the calf, particularly when the foot is dorsiflexed.
Dx?
Diagnostic test?
Tx?

Seven days after an inguinal hernia repair, a patient returns to the clinic because of fever. The wound is red, hot and tender.
Dx?
Management? (3 steps)

Wound infection

Management:
1. Open the wound
2. Drain the pus
3. Pack it and leave it open

None

Two weeks after an open cholecystectomy a patient develops fever and leukocytosis. The wound is healing well and does not appear to be infected.
Dx?
Where is greatest possibility? (2)
Diagnostic test?
Tx?

Dx: Deep Abscess

Places: Subphrenic or Subhepatic
(Had the operation been an appendectomy, pelvic abscess would be the first pick)

Diagnostic test: CT scan to find the abscess and to guide the radiologist for the (Tx) Percutaneous Drainage.

None

On the fifth post-operative day after a right hemicolectomy for cancer, the dressings covering the midline abdominal incision are found to be soaked with a clear, pinkish, salmon-colored fluid.
Dx?
Management? (3 steps)

Dx: Wound dehiscence

Management:
1. Keep the patient in bed
2. Tape his belly together
3. Schedule surgery for re-closure of the wound if the patient can take the re-operation.
(If too sick, the development of a ventral incisional hernia may have to be accepted now and repaired later)

None

Following the discovery of the copious, salmon colored, pinkish clear fluid along the post-op abdominal incision, the patient gets out of bed, or sneezes forcefully, and you are confronted with a bucket-full of small bowel
Dx?
Management? (2 steps)

Dx: Evisceration

Management:
1. keep the bowel covered and moist with sterile dressings
2. Rush the patient to the OR for re-closure

None

A 62 year old lady was drinking her morning cup of coffee at the same time she was applying her makeup, and she noticed in the mirror that there was a lump in the lower part of her neck, visible when she swallowed. She consult you for this and on physical exam you ascertain that she indeed has a dominant, 2cm mass on the left lobe of her thyroid as well as two smaller masses on the right lobe. They are all soft and she has no palpable lymph nodes in the neck.
Diagnostic test?

Diagnostic test: FNA

None

A 21 year old college student is found on a routine physical examination to have a single, 2cm nodule in the thyroid gland. The young man had radiation to his head and neck when he was thirteen years old because of persistent acne. His thyroid function tests are normal.
Diagnostic test?
Tx?

Diagnostic test: FNA

Tx: Surgical removal
(due to radiation leading to cancer)

None

A 44 year old lady has a palpable mass in her thyroid gland. She also describes losing weight in spite of a ravenous appetite, palpitations and heat intolerance. She is a thin lady, fidgety and constantly moving, with moist skin and a pulse rate of 105.
Dx?
Management/test? (3 steps)
Tx?

A 22 year old male has a 2 cm round firm mass in the lateral aspect of his neck, which has been present for four months. Clinically this is assumed to be an enlarged jugular lymph node and it is eventually removed surgically. The pathologist reports that the tissue removed is normal thyroid tissue.
Dx?
Diagnostic test?
Tx?

Dx: Follicular Carcinoma of the Thyroid (metastitic)
(There is no such thing as “lateral aberrant thyroid”)

Diagnostic test: Look for the primary with a Thyroid Scan.

Tx: Eventually Surgery

None

An automated blood chemistry panel done during the course of a routine medical examination indicates that an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently between 10.5 and 12.6. Serum phosphorus is low.
Dx?
Diagnostic test? (2)
Tx?

A 32 year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (she had not been aware of such diagnosis beforehand). It is also ascertained that she has been amenorrheic and shaving for the past couple of years. She has gross centripetal obesity, with moon fascies and Buffalo hump, and thin, bruised extremities. A picture from 3 years ago shows a person of very different, more normal appearance
Dx?
Diagnostic test? (3 steps)
Tx?

Dx: Cushings Dz
(The appearance is so typical, that you will probably be given a photograph on the test, with an accompanying brief vignette)

A 28 year old lady has virulent peptic ulcer disease. Extensive medical management including eradication of H.Pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea.
Dx?
Diagnostic test? (2 steps)
Tx?

A second year medical student is hospitalized for a neurological work-up for a seizure disorder of recent onset. During one of his convulsions it is determined that his blood sugar is extremely low. Further work-up shows that he has high levels of insulin in the blood with low levels of C-peptide.
Dx?
Management?

Dx: Exogenous administration of insulin
(If the C-peptide had been high along with the insulin level, the diagnosis would have been insulinoma)

Management: Psychiatric evaluation and counseling
(He is faking the disease. If it had been insulinoma, CT scan or MRI looking for the tumor in the pancreas, to be subsequently removed surgically)

None

A 48 year old lady has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kinds of “herbs and unguents”. She is thin, has mild stomatitis and mild diabetes mellitus.
Dx?
Diagnostic test? (2)
Tx?
If this Tx is not possible, what can be done? (2)

If inoperable:
1. Somatostatin can help symptomatically
2. Streptozocin is the indicated chemotherapeutic agent

None

A 45 year old lady comes to your office for a “regular checkup”. On repeated determinations you confirm the fact that she is hypertensive. When she was in your office three years ago, her blood pressure was normal. Laboratory studies at this time show a serum sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium concentration of 2.1 mEq/L. The lady is taking no medications of any kind.
Dx? (2 possible)
Diagnostic test? (2 steps)
Tx for each?

A thin, hyperactive 38 year old lady is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration and pallor, but by the time she gets to her doctor’s office she checks out normal in every respect.
Dx?
Diagnostic test? (2 steps)
Medication before surgery?

A 17 year old man is found to have a blood pressure of 190/115. This is checked repeatedly in both arms and it is always found to be elevated, but when checked in the legs it is found to be normal.
Dx?
Diagnostic test? (2 steps)
Tx?

A 23 year old lady has had severe hypertension for two years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen.
Dx?
Diagnostic test?
Tx? (2 possible)

A 72 year old man with multiple manifestations of arteriosclerotic occlusive disease has hypertension of relatively recent onset, and is refractory to the usual medical therapy. He has a faint bruit over the upper abdomen.
Dx?

Dx: Renovascular Hypertension due to arteriosclerotic plaque at the origin of the Renal Artery…or arteries
(this is usually bilateral)

None

Within eight hours after birth, it is noted that a baby has excessive salivation. A small, soft nasogastric tube is inserted and the baby is taken to X-Ray to have a “babygram” done. The film shows the tube coiled back upon itself in the upper chest. There is air in the gastrointestinal tract.
Dx?
Management?
Tx?

Dx: Tracheo-esophageal fistula
(the most common type with proximal blind esophageal pouch and distal TE fistula)

Management:
1. Rule-out the associated anomalies (“VACTER”: vertebral, anal, cardiac, TE and renal/radial). The vertebral and radial will be seen in the same X-ray you already took, you need Echo for the heart, Sonogram for the kidneys and Physical Exam for the anus.

Tx: Surgical repair

None

A newborn baby is found on physical exam to have an imperforate anus.

Management? (2 steps)

Management:
1. This is part of the “VACTER” (vertebral, anal, cardiac, TE and renal/radial) group, so look for the others as mentioned.
2. For the imperforate anus, look for a fistula nearby (to the vagina in little girls, to the perineum in little boys), which will help determine the level of the blind pouch and the timing and type of surgery (primary repair versus colostomy and repair later).

None

A newborn baby is noted to be tachypneic, cyanotic and grunting. The abdomen is scaphoid and there are bowel sounds heard over the left chest. An X-Ray confirms that there is bowel in the left thorax. Shortly thereafter, the baby develops significant hypoxia and acidosis
Dx?
Management? (4 together)
Tx?

Dx: Congenital Diaphragmatic Hernia

Management:
1. keep the kid alive with endotracheal intubation
2. Hyperventilation (careful not to blow up the other lung)
3. Sedation
4. NG suction
(Tx: The main problem is the hypoplastic lung. It is better to wait 36 to 48 hours to do Surgery to allow transition from fetal circulation to newborn circulation)

None

At the time of birth it is noted that a child has a large abdominal wall defect to the right of the umbilicus. There is a normal cord, but protruding from the defect there is a matted mass of angry looking, edematous bowel loops.
Dx?
Tx?

Dx: Gastroschisis

Tx: Pediatric Surgeon must get the bowel back into the belly; they may need to use a silicon “silo” to gradually close the abdominal wall defect.

None

A newborn baby is noted to have a shiny, thin, membranous sac at the base of the umbilical cord. Inside the sac one can see part of the liver, and loops of normal looking bowel.
Dx?
Management?
Tx?

Dx: Omphalocele

Management: Look for other congenital defects. These kids can have a host of other congenital defects
Tx: Repair is performed by a Pediatric surgeon

None

A newborn is noted to have a moist medallion of mucosae occupying the lower abdominal wall, above the pubis and below the umbilicus. It is clear that urine is constantly bathing this congential anomaly.
Dx?
what is important regarding this repair?

Dx: Exstrophy of the urinary bladder

Important: Repair must be done within the first 48 hours, or it will not have a good chance to succeed. It takes time to arrange for transfer of a newborn baby to a distant city that specializes in this repair. If a day or two are wasted before arrangements are made, it will be too late

None

Half an hour after the first feed, a baby vomits greenish fluid. The mother had polyhydramnios and the baby has Down’s syndrome. X-Ray shows a “double bubble sign”: a large air fluid level in the stomach, and smaller one in the first portion of the duodenum. There is no gas in the rest of the bowel.
Dx? (2 possible)
Management?
Tx?

Half an hour after the first feed, a baby vomits greenish fluid. X-Ray shows a "double bubble sign”: a large air fluid level in the stomach, and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the duodenum, in loops that are not distended.
Dx? (3 possibilities)
Diagnostic test?

A newborn baby has repeated green vomiting during the first day of life, and does not pass any meconium. Except for abdominal distention, the baby is otherwise normal. X-Ray shows multiple air fluid levels and distended loops of bowel.
Dx?
Cause?

Dx: Intestinal atresia

Cause: Vascular accident in utero
(thus there are no other congenital anomalies to look for, but there may be multiple points of atresia)

None

A very premature baby develops feeding intolerance, abdominal distention and a rapidly dropping platelet count. The baby is four days old, and was treated with indomethacin for a patent ductus.
Dx?
Management? (3 together)
Reasons for surgical Tx? (3)

Tx: Surgical intervention if they develop abdominal wall erythema, air in the biliary tree or pneumoperitoneum

None

A three day old, full term baby is brought in because of feeding intolerance and bilious vomiting. X-Ray shows multiple dilated loops of small bowel and a “ground glass” appearance in the lower abdomen. The mother has cystic fibrosis.
Dx?
Management? (3 steps)

Dx: Meconium Ileus

Management:
1. Gastrografin enema may be both diagnostic and therapeutic, so it is the obvious first choice.
2. If unsuccessful, surgery may be needed.
3. The kid has cystic fibrosis, and management of the other manifestations of the disease will also be needed

None

A three week old baby has had “trouble feeding” and it is not quite growing well. He now has bilious vomiting and is brought in for evaluation. X-Ray shows a classical “double bubble”, along with normal looking gas pattern in the rest of the bowel.
Dx?
Diagnostic test?
Tx?

Dx: Malrotation of the bowel
(not all will show up on day one)

Diagnostic test: Contrast enema to verify the malrotation

Tx: Emergency surgery

None

A 3 week old first-born, full term baby boy began to vomit three days ago. The vomiting is projectile, has no bile in it, follows each feeding and the baby is hungry and eager to eat again after he vomits. He looks somewhat dehydrated and has visible gastric peristaltic waves and a palpable “olive size” mass in the right upper quadrant.
Dx?
Management? (2 steps)
Tx?

An 8 week old baby is brought in because of persistent, progressively increasing jaundice. The bilirubin is significantly elevated and about two thirds of it is conjugated, direct bilirubin. Ultrasound rules out extrahepatic masses, serology is negative for hepatitis and sweat test is normal.
Dx?
Diagnostic test? (2)
Tx?

Dx: Biliary Atresia

Diagnostic test:
1. HIDA scan
2. Percutaneous Liver Biopsy

Tx: Exploratory laparotomy

None

A two month old baby boy is brought in because of chronic constipation. The kid has abdominal distention, and plain X-Rays show gas in dilated loops of bowel throughout the abdomen. Rectal exam is followed by expulsion of stool and flatus, with remarkable improvement of the distention.
Dx?
Diagnostic test? (2)
Tx?

A 9 month old, chubby, healthy looking little boy has episodes of colicky abdominal pain that make him double up and squat. The pain lasts for about one minute, and the kid looks perfectly happy and normal until he gets another colick. Physical exam shows a vague mass on the right side of the abdomen, an “empty” right lower quadrant and currant jelly stools.
Dx?
Management?
Tx?

Dx: Intussusception

Management: Barium enema is both diagnostic and therapeutic in most cases.

Tx: If reduction is not achieved radiologically, exploratory laparotomy and manual reduction will be needed

None

A one year old baby is referred to the University Hospital for treatment of a subdural hematoma. In the admission examination it is noted that the baby has retinal hemorrhages.
Dx?

Child Abuse

None

A one year old child is brought in with second degree burns of both buttocks. The stepfather relates that the child fell into a hot tub.
Dx?

Child Abuse

None

A three year old girl is brought in for treatment of a fractured humerus. The mother relates that the girl fell from her crib. X-Rays show evidence of other older fractures at various stages of healing in different bones.
Dx?

Child Abuse

None

A 4 year old boy passes a large bloody bowel movement.
Dx?
Diagnostic test?
Tx?

A 15 year old girl has a round, 1cm cystic mass in the midline of her neck at the level of the hyoid bone. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for at least 10 years, but only recently bothered the patient because it got infected and drained some pus.
Dx?
Tx?

Dx: Thyroglossal Duct Cyst

Tx: Sistrunk operation
(removal of the mass and the track to the base of the tongue, along with the medial segment of the hyoid bone).

None

An 18 year old woman has a 4cm fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that is has been there at least 10 years, although she thinks that it has become somewhat larger in the last year or two. A CT scan shows the mass to be cystic.
Dx?
Tx?

Dx: Branchial Cleft Cyst

Tx: Elective surgical removal

None

A 6 year old child has a mushy, fluid filled mass at the base of the neck, that has been noted for several years. The mass is about 6 cm. in diameter, occupies most of the supraclavicular area and seems by physical exam to go deeper into the neck and chest.
Dx?
Diagnostic test?
Tx?

Dx: Cystic hygroma

Diagnostic test: CT scan to see how deep this thing goes.
(They can extend down into the chest and mediastinum)

Tx: Surgical removal will eventually be done

None

A 22 year old lady notices an enlarged lymph node in her neck. The node is in the jugular chain, measures about 1.5cm, is not tender, and was discovered by the patient yesterday. The rest of the history and physical exam are unremarkable.
Management?

Management: Reschedule an appointment for 3 weeks to see its progress

(If the node has gone away by then, it was inflammatory and nothing further is needed. If it’s still there, it could be neoplastic and something needs to be done)

None

A 22 year old lady seeks help regarding an enlarged lymph node in her neck. The node is in the jugular chain, measures about 2cm, is firm, not tender, and was discovered by the patient six weeks ago. There is a history of low grade fever and night sweats for the past three weeks. Physical examination reveals enlarged lymph nodes in both axillas and in the left groin.
Dx?
Diagnostic test?

Dx: Lymphoma (most likely)

Disgnostic test: Tissue diagnosis will be needed. You can start with FNA of the available nodes, but eventual node biopsy will be needed to establish not only the diagnosis but also the type of lymphoma

None

A 72 year old man has 4cm hard mass in the left supraclavicular area. The mass is movable, non tender and has been present for three months. The patient has had a 20 pound weight loss in the past two months, but is otherwise asymptomatic.
Dx?
Management? (2)

Dx: Malignant mets to a supraclavicular node from a primary tumor below the neck.

Management:
1. Look for the obvious primary tumors: lung, stomach, colon, pancreas, and kidney
2. The node itself will eventually be Biopsied

None

A 69 year old man who smokes and drinks and has rotten teeth has a hard, fixed, 4cm mass in his neck. The mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the Thyroid cartilage. It has been there for at least six months, and it is growing.
Dx?
Diagnostic test?

Dx: Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck
(oro-pharyngeal-laryngeal territory)

A 69 year old man who smokes and drinks and has rotten teeth has unilateral ear ache that has not gone away in 6 weeks. Physical examination shows serious otitis media on that side, but not on the other.
Dx?
Diagnostic test?

A 52 year old man complains of hearing loss. When tested he is found to have unilateral sensory hearing loss on one side only. He hoes not engage in any activity (such as sport shooting) that would subject that ear to noise that spares the other side.
Dx?
Diagnostic test?

Dx: Acoustic Nerve Neuroma
(Unilateral versions of common ENT problems in the adult suggest malignancy. Note that if the hearing loss had been conductive, a Cerumen Plug would be the obvious first diagnosis)

Diagnostic test: MRI looking for the tumor

None

A 56 year old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full blown paralysis to become obvious, and it has been present now for three months. It affects both the forehead as well as the lower face.
Dx?
Diagnostic test?

Dx: Gradual, unilateral nerve paralysis suggests a neoplastic process

Diagnostic test: Gadolinium enhanced MRI

None

A 45 year old man presents with a 2cm firm mass in front of the left ear, which has been present for four months. The mass is deep to the skin and it is painless. The patient has normal function of the facial nerve.
Dx?
Management?

Dx: Pleomorphic adenoma (mixed tumor) of the parotid gland

Management: Referral to a head and neck surgeon for formal superficial parotidectomy
(FNA is appropriate, but the point of the question will be to bring out the fact that parotid masses are never biopsied in the office or under local anesthesia)

None

A 65 year old man present with a 4cm hard mass in front of the left ear, which has been present for six months. The mass is deep to the skin and it is fixed. He has constant pain in the area, and for the past two months has had gradual progression of left facial nerve paralysis. He has rock-hard lymph nodes in the left neck.
Dx?
Management?

Dx: Cancer of the parotid gland

Management: Referral to a head and neck surgeon for formal superficial parotidectomy
(Amateurs should not mess with parotid)

A 4 year old child is brought by his mother to the emergency room because “she is sure that he must have swallowed a marble”. The kid was indeed playing with marbles and apparently completely healthy when he was put to bed, but four hours later he had developed inspiratory stridor, a fever of 103 and obvious respiratory distress. The kid is sitting up, leaning forward, drooling at the mouth and looking very sick indeed.
Dx?
Diagnostic test?
Management? (3)
what if bradycardia develops?

Dx: Acute Epiglotitis

Diagnostic test: Lateral X-ray of the neck

Management: A real emergency where expert help is needed!
1. Ready to use bag and mask if needed.
2. OR for Nasotracheal Intubation.
3. Start IV antibiotics along the way for H.Pylori

Bradychardia develops: Atropine will help, but hypoxia is the problem.

None

A 45 year old lady with a history of a recent tooth infection shows up with a huge, hot, red, tender, fluctuant mass occupying the left lower side of her face and upper neck, including the underside of the mouth. The mass pushes up the floor of the mouth on that side. She is febrile.
Dx?
Tx? (2 together)

Dx: Ludwigs’ Angina
(An abscess of the floor of the mouth)

Tx:
1. Tracheostomy
2. Incision & Drainage of the abscess

None

A 29 year old lady calls your office at 10 AM with the history that she woke up that morning with one side of her face paralyzed.
Dx?
Management?

Dx: Bell’s palsy

Management: Immediate anti-viral medication
(the process is idiopathic and will resolve spontaneously in most cases)

A patient with multiple trauma from a car accident is being attended to in the emergency room. As multiple invasive things are done to him, he repeatedly grimaces with pain. The next day it is noted that he has a facial nerve paralysis on one side.
Dx?

Dx: Paralysis from Edema

(Trauma to the temporal bone can certainly transect the facial nerve, but when that happens the nerve is paralyzed right there and then. Nothing needs to be done...it will correct itself)

None

Your office receives a phone call from Mrs. Rodriguez. You know this middle aged lady very well because you have repeatedly treated her in the past for episodes of sinusitis. In fact, six days ago you started her on decongestants and oral antibiotics for what you diagnosed as frontal and ethmoid sinusitis. Now she tells you over the phone that ever since she woke up this morning, she has been seeing double.
Dx? (2 possible)
Management? (3 steps)
Dx test?

Dx: Cavernous Sinus Thrombosis or Orbital Cellulitis

Management: This is a real emergency (fact that is most likely questioned).
1. Immediate Hospitalization,
2. high dose IV Antibiotic treatment
3. Surgical Drainage of the paranasal sinuses or the orbit.

Dx Test: CT scan
(which will also be needed to guide the surgery)

None

A 10 year old girl has epistaxis. Her mother says that she picks her nose all the time.
Dx?
Tx?

Dx: Bleeding from the Anterior part of the septum

Tx: Phenylephrine spray and local pressure

None

An 18 year old boy has epistaxis. The patient denies picking his nose. No source of anterior bleeding can be seen by physical examination.
Dx? (2 possible)

A 72, hypertensive male, on aspirin for arthritis, has a copious nosebleed. His blood pressure is 220/105 when seen in the E.R. He says he began swallowing blood before it began to come out through the front of his nose.
Dx?
Management? (2)

Dx: Epistaxis secondary to hypertension

Management:
1. Lower BP with Medication
2. Involve ENT

(These are serious problems that can end up with death)

None

A 57 year old man seeks help for “dizziness”. On further questioning he explains that the room spins around him
Dx?
Management?

During a school physical exam, a 12 year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognized that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited.
Dx?
Diagnostic test?
Tx?

Dx: Atrial septal defect

Diagnostic test: Echocardiography

Tx: Surgical closure of the defect

None

A three month old boy is hospitalized for ‘failure to thrive”. He has a loud, pansystolic heart murmur best heard at the left sternal border. Chest X-Ray shows increased pulmonary vascular markings.
Dx?
Diagnostic test?
Tx?

A 6 year old boy is brought to the U.S. by his new adoptive parents, from an orphanage in Eastern Europe. The kid is small for his age, and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with squatting. He has a systolic ejection murmur in the left third intercostal space. Chest X-Ray shows a small heart, and diminished pulmonary vascular markings. EKG shows right ventricular hypertrophy.
Dx?
Diagnostic test?

Dx: Tetralogy of Fallot

Diagnostic test: Echocardiogram

None

A 72 year old man has a history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best heard at the second intercostal space and along the left sternal border.
Dx?
Diagnostic test?
Definitive Tx?
When is it indicated? (2)

Dx: Aortic Stenosis

Diagnostic test: Echocardiogram

Tx: Surgical Valvular replacement

Surgery indications:
1. gradient of more than 50 mm.Hg.
2. indication of CHF, angina or syncope

None

A 72 year old man has been known for years to have a wide pulse pressure and a blowing, high-pitched, diastolic heart murmur best heard at the second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation.
Heart Dx?
Diagnostic test?
Next step?

Dx: Chronic Aortic Insufficiency

Diagnostic test: Echocardiogram

Next step: Aortic valve replacement

None

A 26 year old drug-addicted man develops congestive heart failure over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical exam done a few weeks ago, when he had attempted to enroll in a detoxification program was completely normal.
Heart Dx?
Management/Tx? (2 together)

Dx: Acute Aortic Insufficiency due to Endocarditis

Management:
1. Emergency valve replacement
2. Antibiotics for a long time

None

A 35 year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis. She has had these progressive symptoms for about 5 years. She looks thin and cachectic, has atrial fibrillation and a low-pitched, rumbling diastolic apical heart murmur. At age 15 she had rheumatic fever.
Heart disorder Dx?
Diagnostic test?
Tx?

Dx: Mitral stenosis

Diagnostic test: Echocardiogram

Tx: Eventually surgical mitral valve repair

None

A 55 year old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea and atrial fibrillation. She has an apical, high pitched, holosystolic heart murmur that radiates to the axilla and back.
Dx?
Diagnostic test?
Tx? (2 possible)

Dx: Mitral Regurgitation

Diagnostic test: Echocardiogram

Tx: eventually surgical repair of the valve (Annuloplasty) or possibly valve replacement

None

A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type two diabetes mellitus and has high cholesterol.

Management?

It’s a heart attack waiting to happen...

Management: Cardiac Catheterization
(to see if he is a suitable candidate for coronary revascularization)

None

A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type two diabetes mellitus and has high cholesterol. Cardiac catheterization demonstrates 70% occlusion of three coronary arteries, with good distal vessels. His left ventricular ejection fraction is 65%
Management?

Management: Angioplasty

(He is lucky. He has good distal vessels...smokers and diabetics often do not...and enough cardiac function left. He clearly needs coronary bypass, and with 3-vessel disease there should be no argument for angioplasty instead of surgery)

None

On a routine pre-employment physical examination, a chest X-Ray is done on a 45 year old chronic smoker. A “coin lesion” is found in the upper lobe of the right lung.
Dx?
Next step?

Dx: Cancer of the lung

Next step: Find and older chest X-Ray if one is available (from one or more years ago). If an older X-Ray has the same unchanged lesion, it is not likely cancer. No further work up is needed now, but the lesion should be followed with periodic X-Rays.

None

A 54 year old man with a 40 pack/year history of smoking gets a chest X-Ray because of persistent cough. A peripheral, 2cm “coin lesion” is found in the right lung. A chest X-Ray taken two years ago had been normal. CT scan shows no calcifications in the mass and no enlarged peribronchial or peritracheal lymph nodes. The man has good pulmonary function and is otherwise in good health.
Dx?
Diagnostic test?
If first Dx test does not work, what are 2 others (in order)?

Dx: Cancer of the lung

Diagnostic test:
1. Start with Bronchoscopy and washings,
2. if unrewarding go to Percutaneous Needle Biopsy
3. if still unsuccessful go to Open Biopsy
(Thoracotomy and Wedge Resection)

None

A 72 year old chronic smoker with severe COPD is found to have a central, hilar mass on chest X-Ray. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 1100, and a ventilation/perfusion scan shows that 60% of his pulmonary functions comes from the affected lung.
Management/Tx?

Management: It takes an FEV1 of at least 800 to survive surgery and not be a pulmonary cripple afterwards. If this fellow got a pneumonectomy (which he would need for a central tumor) he would be left with an FEV1 of 440. No way... Don’t do any more tests. He is not a surgical candidate.

Tx: pursue Chemotherapy and Radiation

None

A 62 year old chronic smoker has an episode of hemoptysis. Chest X-ray shows a central hilar mass. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 2200, and a ventilation/perfusion scan shows that 30% of his pulmonary function comes from the affected lung.
Diagnostic test?
Tx?

A 33 year old lady is undergoing a diagnostic work-up because she appears to have Cushing’s syndrome. Chest X-Ray shows a central, 3cm round mass on the right lung. Bronchoscopy and biopsy confirm a diagnosis of small cell carcinoma of the lung.
Management for cancer?

Management: Radiation and chemotherapy.

(Small cell lung cancer is not treated with surgery, and thus we have no need to determine FEV1 or nodal status)

None

A 54 year old right handed laborer notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. What really concerned him, though, is that in the last few episodes he also experienced transitory vertigo, blurred vision and difficulty articulating his speech. Angiogram demonstrates retrograde flow through the vertebral artery.
Dx?
Management/Tx?

Dx: Subclavian Steal syndrome

(A combination of “claudication of the arm” with posterior brain neurological symptoms is classical for this)

Management: Angiographic study (If you had been given the vignette without it), then Vascular surgery

None

A 62 year old man is found on physical exam to have a 6cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus
Dx?
Tx?

Dx: Abdominal Aortic Aneurysm

Tx: Elective surgical repair

None

A 62 year old man has vague, poorly described epigastric and upper back discomfort. He has been found on physical exam to have a 6cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. The mass is tender to palpation.
Dx?
Management?

Dx: Abdominal Aortic Aneurysm that is beginning to leak.

Management: Get a consultation with the vascular surgeons today

None

A 68 year old man is brought to the ER with excruciating back pain that began suddenly 45 minutes ago. He is diaphoretic and has a systolic blood pressure of 90. There is an 8cm pulsatile mass palpable deep in his abdomen, between the xiphoid and the umbilicus.
Dx?
Tx?

Dx: Abdominal Aortic Aneurysm, rupturing right now.

Tx: Emergency surgery

None

A retired businessman has claudication when walking more than 15 blocks.

Management?

Management: If he is smoking he should quit; otherwise he needs nothing

(Vascular surgery, or angioplasty and stenting are palliative procedures. They do not cure arteriosclerotic occlusive disease. Claudication has an unpredictable course, thus there is no advantage to an “early operation”)

None

A 56 year old postman describes severe pain in his right calf when he walks two or three blocks. The pain is relieved by resting 10 or 15 minutes, but recurs if he walks again the same distance. He can not do his job this way, and he does not qualify yet for retirement, so he is most anxious to have this problem resolved. He does not smoke.

Diagnostic test? (2 steps)
Tx?

Diagnostic test:
1. Start with Doppler studies
2. If he has significant gradient, Arteriogram comes next

Tx: Bypass surgery or stenting

None

A patient consults you because he “can not sleep”. On questioning it turns out that he has pain in the right calf, which keeps him from falling asleep. He relates that the pain goes away if he sits by the side of the bed and dangles the leg. His wife adds that she has watched him do that, and she has noticed that the leg which was very pale when he was lying down becomes deep purple several minutes after he is sitting up. On physical exam the skin of that leg is shiny, there is no hair and there are no palpable peripheral pulses.
Dx?
Diagnostic test? (2 steps)
Tx?

Dx: Claudication

Dx test:
1. Start with Doppler studies
2. If he has significant gradient, Arteriogram comes next

Tx: Bypass surgery or stenting

None

A 45 year old man shows up in the ER with a pale, cold, pulseless, paresthetic, painful and paralytic lower extremity. The process began suddenly two hours ago. Physical exam shows no pulses anywhere in that lower extremity. Pulse at the wrist is 95 per minute, grossly irregular.
Dx?
Tx?

Dx: Embolization by the broken-off tail of a clot from the left atrium

Tx: Emergency surgery with use of Fogarty catheters to retrieve the clot

None

A 74 year old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after it’s onset. His blood pressure is 220/100, he has unequal pulses in the upper extremities and he has a wide mediastinum on chest X-Ray. Electrocardiogram and cardiac enzymes show that he does not have a myocardial infarction
Dx?
Management w/ high BP? (2)
Normal BP?
Tx? (depends on area; 2 possible)

Dx: Dissecting aneurysm of the thoracic Aorta

Management:
1. if high BP, beta-blockers or IV nitrates to lower BP
(b/c forces that dissected the vessel plus the force of the dye injection could further shear the aorta)
2. Arteriogram
(first if BP is normal)

A 62 year old right handed man has transient episodes of weakness in the right hand, blurred vision, and difficulty expressing himself. There is not associated headache, the episodes last about 5 or 10 minutes at the most, and they resolve spontaneously. Fundoscopic examination reveals highly refractile crystals in the left retinal artery.
Dx?
Diagnostic test?
Tx?

Dx: Transient Ischemic Attacks
in the territory of the left carotid artery
(probably an ulcerated plaque at the left carotid bifurcation)

Diagnostic test: Angiogram

Treatment: Carotid endarterectomy

None

A 61 year old man presents with a one year history of episodes of vertigo, diplopia, blurred vision, dysarthria and instability of gait. The episodes last several minutes, have no associated headache and leave no neurological sequela.
Dx?
Diagnostic test?
Tx?

Dx: Transient Ischemic Attacks
(but now the vertebrals may be involved)

Diagnostic test: Arteriogram that examines all the arteries going to the brain (i.e. an aortic arch study)

Tx: Vascular surgery will follow

None

A 60 year old diabetic male presents with abrupt onset of right third nerve paralysis and contralateral hemiparesis. There was no associated headache. The patient is alert, but has the neurological deficits mentioned.
Dx?
Diagnostic test?

Dx: Stroke
(Neurological catastrophes that begin suddenly and have no associated headache are vascular occlusive)

Diagnostic test: CT scan

(Vascular surgery in the neck is designed to prevent strokes, not to treat them once they happen)

None

A 64 year old black man complains of a very severe headache of sudden onset and then lapses into a coma. Past medical history reveals untreated hypertension and examination reveals a stuporous man with profound weakness in the left extremities.
Dx?
Diagnostic test?
Tx?

A 39 year old lady presents to the ER with a history of a severe headache of sudden onset that she says is different and worse than any headache she has ever had before. She is given pain medication and sent home. She improves over the next few days, but ten days after the initial visit she again gets a sudden, severe and singular diffuse headache and she returns to the ER. This time she has some nuchal rigidity on physical exam.
Dx?
Diagnostic test? (2 steps)
Tx?

Dx: Subarachnoid bleeding from an intracranial aneurysm.
(the nuchal rigidity betrays the presence of blood in the subarachnoid space)

Diagnostic test:
1. CT scan to find bleeder
2. Angiograms will eventually follow, in preparation for (Tx) Surgery to clip the aneurysm

None

A 31 year old nursing student developed persistent headaches that began approximately 4 months ago, have been gradually increasing in intensity and are worse in the mornings. For the past three weeks, she has been having projectile vomiting. Thinking that she may need new glasses, she seeks help from her optometrist, who discovers that she has bilateral papilledema.
Dx?
Diagnostic test?
Management until surgery? (3)

Dx: Brain Tumor

(Neurological processes that develop over a period of a few months and lead to increased intracranial pressure, spell out tumor)

A 42 year old right handed man has a history of progressive speech difficulties and right hemiparesis for five months. He has had progressively severe headaches for the last two months. At the time of admission he is confused, vomiting, has blurred vision, papilledema and diplopia. Shortly thereafter his blood pressure goes up to 190 over 110, and he develops bradychardia.
Dx?
Management? (3 together)
Tx?

Dx: Brain tumor
(but now with two added features...there are localizing signs: left hemisphere, parietal and temporal area...and he manifests the Cushing’s reflex of extremely high intracranial pressure)

A 12 year old boy is short for his age, has bitemporal hemianopsia and has a calcified lesion above the sella in X-Rays of the head.
Dx?
Diagnostic test?
Tx?

Dx: Craniopharyngioma

Diagnostic test: MRI

Tx: Pituitary surgery

None

A 23 year old nun presents with a history of amenorrhea and galactorrhea of six months duration. She is very concerned that other may think that she is pregnant, and she vehemently denies such a possibility.
Dx?
Diagnostic test? (2 steps)
Tx?
If Tx is not possible, what medication?

Dx: Prolactinoma

Diagnostic test:
1. Measure Prolactin level
(Every time you suspect a functioning tumor of an endocrine gland, you measure the appropriate hormone)
2. MRI to see tumor for surgery

Tx: Trans-nasal, trans-sphenoidal

If inoperable: Bromocriptine

None

A 44 year old man is referred for treatment of hypertension. His physical appearance is impressive: he has big, fat, sweaty hands; large jaw and thick lips, large tongue and huge feet. He is also found to have a touch of diabetes. In further questioning he admits to headaches and he produces pictures of himself taken several years ago, where he looks strikingly different.
Dx?
Diagnostic test? (2 steps)
Tx?

Dx: Acromegaly

Diagnostic test:
1. Growth hormone levels
2. MRI for surgery

Tx: Pituitary surgery

None

A 15 year old girl has gained weight and become “ugly”. She shows a picture of herself a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of pimples; her neck has a posterior hump and her supraclavicular areas are round and convex. She has a fat trunk and thin extremities. She has mild diabetes and hypertension.
Dx?
Diagnostic test? (3 steps)
Tx? (3 possible)

A 55 year old lady is involved in a minor traffic accident where her car was hit sideways by another car that she “did not see” at an intersection. When she is tested further it is recognized that she has bitemporal hemianopsia. Ten years ago she had bilateral adrenalectomies for Cushing’s disease.
Dx?
Diagnostic test?
Tx?

Dx: Nelson’s syndrome
(Years ago, before imaging studies could identify pituitary microadenomas, patients with Cushing’s were treated with bilateral adrenalectomy instead of pituitary surgery. In some of those patients the pituitary microadenoma kept on growing and eventually gave pressure symptoms)

Diagnostic test: MRI will show the tumor

Tx: Trans-nasal, trans-sphenoidal surgery will remove it

None

A 42 year old man has been fired from his job because of inappropriate behavior. For the past two months he has gradually developed very severe, “explosive” headaches that are located on the right side, above the eye. Neurologic exam shows optic nerve atrophy on the right, papilledema on the left and anosmia.
Specific Dx?
Diagnostic test?
Tx?

Dx: Brain tumor in the right frontal lobe
(Foster-Kennedy syndrome)

(A little knowledge of neuroanatomy can help localize tumors. The frontal lobe has to do with behavior and social graces, and is near the optic nerve and the olfactory nerve)

Diagnostic test: MRI

Tx: Neurosurgery

None

A 32 year old man complains of progressive, severe generalized headaches that began three months ago are worse in the mornings and lately have been accompanied by projectile vomiting. He has lost his upper gaze and he exhibits the physical finding known as “sunset eyes”.
Specific Dx?
Diagnostic test?
Tx?

Dx: Tumor is in the pineal gland (Parinaud’s syndrome)

Diagnostic test: MRI

Tx: Neurosurgery

None

A six year old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neurological exam demonstrates truncal ataxia.
Specific Dx?
Diagnostic test?
Tx?

Dx: Tumor of the Posterior Fossa.
(Most brain tumors in children are located there, and cerebellar function is affected)

Diagnostic test: MRI

Tx: Neurosurgery

None

A 23 year old man develops severe headache, seizures and projectile vomiting over a period of two weeks. He has low grade fever, and was recently treated for acute otitis media and mastoiditis.
Dx?
Diagnostic test?
Tx?

Dx: Brain abscess
(Signs and symptoms suggestive of brain tumor that develop in a couple of weeks with fever and an obvious source on infection, spell out abscess)

Diagnostic test: These are seen in CT as well as they would on MRI, and the CT is cheaper and easier to get...so pick CT if offered.

Tx: Resected by the neurosurgeons

None

An 18 year old street fighter gets stabbed in the back, just to the right of the midline. He has paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side.
Dx?
Management?

Dx: Spinal cord Hemisection
(Brown-Sequard’s syndrome)

Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.

None

A patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, while showing preservation of vibratory sense and position sense.
Dx?
Management?

Dx: Anterior cord syndrome

Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.

None

An elderly man is involved in a rear end automobile collision where he hyperextends his neck. He develops paralysis and burning pain of both upper extremities while maintaining good motor function in his legs.
Dx?
Management?

Dx: Central Cord syndrome

Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.

None

A 52 year old lady has constant, severe back pain for two weeks. While working on her yard, she suddenly falls and can not get up again. When brought to the hospital she is paralyzed below the waist. Two years ago she had a mastectomy for cancer of the breast.
Dx?
Diagnostic test?
Tx?

Diagnostic test: MRI is the best imaging modality for the spinal cord.

Tx: Neurosurgeons may be able to help if the cord is compressed rather than transected

None

A 45 year old male gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is “like an electrical shock that shoots down his leg”, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg raising test gives excruciating pain.
Dx?
Diagnostic test?
Management? (2 possible)

Dx: Lumbar disk Herniation
(The peak age incidence is 45, and virtually all of these are either L4-L5 or L5-S1)

Diagnostic test: MRI

Management:
1. Bed rest will take care of most of these
2. Neurosurgical intervention only if there is progressive weakness or sphincteric deficits

None

A 79 year old man complains of leg pain brought about by walking and relieved by rest. On further questioning it is ascertained that he has to sit down or bend over for the pain to go away. Standing at rest will not do it. Furthermore, he can exercise for long periods of time if he is “hunched over”, such as riding a bike or pushing a shopping cart. He has normal pulses in his legs.
Dx?
Diagnostic test?
Tx?

Dx: Neurogenic Claudication

Diagnostic test: MRI

Tx: Eventually surgical decompression of this cauda equina

None

A 60 year old man complains of extremely severe, sharp, shooting, “like a bolt of lighting”, pain in his face which is brought about by touching a specific area, and which lasts about 60 seconds. His neurological exam is normal, but it is noted that part of his face is unshaven, because he fears to touch that area.
Dx?
Diagnostic test?
Tx?

Dx: Tic Doloreaux (Trigeminal neuralgia)

Diagnostic test: Rule out organic lesions with MRI

Tx: Anticonvulsants

None

Several months after sustaining a crushing injury of his arm, a patient complains bitterly about constant, burning, agonizing pain that does not respond to the usual analgesic medications. The pain is aggravated by the slightest stimulation of the area. The arm is cold, cyanotic and moist.
Dx?
Management? (2 possible)

In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a “click”, and returned to normal position with a “snapping”.
Dx?
Management?

Dx: Developmental Dysplasia of the hip

Management: Abduction splinting

(Don’t order X-Rays in a newborn. Calcification is still incomplete and you will not see anything)

None

A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the hip is guarded.
Dx?
Diagnostic test?
Management?

Management: Contain the femoral head within the acetabulum by casting and crutches

None

A 13 year old boy complains of pain in the groin (it could be the knee) and is noted by the family to be limping. He sits in the office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and it can not be rotated internally
Dx?
Diagnostic test?
Tx?

Dx: Slipped Capital Femoral Epiphysis
(Forget the details: a bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency)

Diagnostic test: AP and lateral X-Rays

Tx: The orthopedic surgeons will pin the femoral head in place

None

A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotation and you can not examine that hip he will not let you move it. He has elevated sedimentation rate
Dx?
Management? (2 steps)

Dx: Septic Hip
(orthopedic emergency)

Management:
1. Under general anesthesia the hip is aspirated to confirm the diagnosis, and

2. Open arthrotomy is done for drainage

None

A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone.
Dx?
Diagnostic test?

Dx: Acute Hematogenous Osteomyelitis

Diagnostic test: Bone Scan
(don’t fall for the X-Ray option. X-Ray will not show anything for two weeks)

None

A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a “hump” is noted over her right thorax. The patient has not yet started to menstruate.
Management? (3 steps)

Management:
1. Baseline x-rays to monitor progression
2. Bracing may be needed to arrest progression
3. Pulmonary function could be limited if there is large deformity

(The point is that scoliosis may progress until skeletal maturity is reached. At the onset of menses skeletal maturity is about 80%, so this patient still has a way to go)

None

A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X-Rays show a large bone tumor, with “sunburst” pattern and periosteal “onion skinning”.
Dx? (2 possible)
Management?

Dx: Osteogenic Sarcoma or Ewing’s Sarcoma

Management: The point of the vignette is that you do not mess with these. Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon (they see one of these every three years), but to a specialist on bone tumors

None

A 66 year old lady picks up a bag of groceries and her arm snaps broken
Dx?
Diagnostic test? (3 steps)

Dx: A pathologic fracture (i.e: for trivial reasons) means bone tumor, which in the vast majority of cases will be metastatic.

A 58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months, it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8cm in diameter
Dx?
Diagnostic test?

Dx: Soft tissue sarcoma is the concern

Diagnositic test: MRI
(Leave biopsy and further management to the experts)

None

A middle aged homeless man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicit excruciating pain. Pulses at the wrist are normal
Dx?
Tx?

Dx: Compartment syndrome

Tx: Emergency Fasciotomy

None

A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture
Management?

Management: Remove the cast

(The point of this vignette is that you never give pain medication and do nothing else for pain under a cast. The cast has to come off right away. It may be too tight, it may be compromising blood supply, it may have rubbed off a piece of skin)

None

A young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration
Management?

Management: Reduction in the OR within 6 hours

(The point of this one is that open fractures are orthopedic emergencies. This fellow may need to have other problems treated first...abdominal bleeding, intracranial hematomas, chest tubes, etc, but the open fracture should be in the OR getting cleaned and reduced within six hours of the injury)

None

A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. There is numbness in a small area of her shoulder, over the deltoid muscle.
Dx?
Diagnostic test?
Tx?

Dx: Anterior Dislocation of the Shoulder, with Axillary nerve damage

Diagnostic test: Get AP and lateral X-Rays

Tx: Reduce

None

After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by “Doc in a Box”, where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next day she still has the same pain and inability to move the arm. She comes to the ER with the arm held close to her body, in a “normal” (i.e., not externally rotated, but internally rotated) position
Dx?
Diagnostic test? (specific)

Dx: Posterior Dislocation of the Shoulder
(Very easy to miss on regular X-Rays)

Diagnostic test: Get X-Rays again but order Axillary view or Scapular Lateral

None

A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity shortened, adducted, and internally rotated.
Dx?
Diagnostic test?
Tx?

Dx: Posterior Dislocation of the Hip.
(Emergency: The blood supply of the femoral head is tenuous, and delay in reduction could lead to avascular necrosis)

Diagnostic test: X-Rays

Tx: Emergency reduction

None

A 77 year old man falls in the nursing home and hurts his hip. X-Rays show that he has a displaced femoral neck fracture
Dx?
Tx?

Dx: Hip fracture

Tx: Metal prosthetic surgery
(The point of this vignette is that blood supply to the femoral head is compromised in this setting and the patient is better off with a metal prosthesis put in, rather than an attempt at fixing the bone. With intertrochanteric fractures on the other hand, the broken bones can be pinned together and expected to heal)

None

A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee.
Management? (3 steps)

Management:
1. Check pulses
2. Arteriogram
3. Reduction

(The point here is that posterior dislocation of the knee can nail the popliteal artery. Attention to integrity of pulses, arteriogram and prompt reduction are the key issues)

None

A young recruit complains of localized pain in his tibia after a forced march at boot camp. He is tender to palpation over a very specific point on the bone, but X-Rays are normal
Dx?
Management? (2 steps)

Dx: Stress Fracture
(The lesson here is that stress fractures will not show up radiologically until 2 weeks later)

Management:
1. Treat the guy as if he had a fracture (cast)
2. Repeat the X-Ray in 2 weeks

None

A man who fell from a second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to order.
What are the rules for ordering x-rays? (3)

Here are the rules:

1. Always get X-Rays at 90 degrees to each other (for instance, AP and lateral)

2. Always include the joints above and below

3. if appropriate (this case is) check the other bones that might be in the same line of force (here the lumbar spine)

None

A healthy 24 year old man steps on a rusty nail at the stables where he works as a horse breeder. Three days later he is brought to the ER moribund, with a swollen, dusky foot, in which one can feel gas crepitation.
Dx?
Management? (3 steps: 1 med, 1 surgery, 1 other)

A 67 year old diabetic has an indolent, unhealing ulcer at the heel of the foot
Management? (3 steps)

Management:
1. control the diabetes
2. keep the ulcer clean
3. keep the leg elevated...and be resigned to the thought that you may end up amputating the foot

None

A 67 year old smoker with high cholesterol and coronary disease has an indolent, unhealing ulcer at the tip of his toe. The toe is blue, and he has no peripheral pulses in that extremity.
Dx?
Diagnostic test? (2 steps)
Tx?

Dx: Ischemic Ulcers
(usually are at the farthest away pint from where the blood comes)

A 44 year old, obese woman has an indolent, unhealing ulcer above her right malleolus. The skin around it is thick and hyperpigmented. She has frequent episodes of cellulitis, and has varicose veins
Dx?
Management?
Tx?

Dx: Venous Stasis Ulcer

Management: Unna boot and Support stockings

Tx: Varicose vein surgery

None

A 14 year old boy presents in the Emergency Room with very severe pain of sudden onset in his right testicle. There is no fever, pyuria or history of recent mumps. The testis is swollen, exquisitely painful, “high riding”, and with a “horizontal lie”. The cord is not tender.
Dx?
Tx?

Dx: Testicular Torsion
(urological emergency)

Tx: Emergency surgery to save the testicle

None

A 24 year old man presents in the emergency room with very severe pain of recent onset in his right scrotal contents. There is fever of 103 and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The cord is also very tender.
Dx?
Diagnostic test?
Tx?

Dx: Acute Epididimitis

Diagnostic test: Ultrasound (to rule-out torsion)

Tx: Antibiotics

(The differential diagnosis is with testicular torsion. Torsion is a surgical emergency. Epididimitis is not. Don’t rush this guy to the OR. If the vignette is not clear-cut, i.e: and adolescent that looks like epidimitis, but could be torsion, pick a sonogram to rule out torsion before you choose the non-surgical option)

None

A 72 year old man is being observed with a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature spike to 104 and flank pain.
What should be given to him?
What is initial Tx? (2)

(Obstruction and Infection of the urinary tract: a true urological emergency. In a septic patient stone extraction would be hazardous)

None

An adult female relates that five days ago she began to notice frequent, painful urination, with small volumes of cloudy and malodorous urine. For the first three days she had no fever, but for the past two days she has been having chills, high fever, nausea and vomiting. Also in the past two days she has had pain in the right flank. She has had no treatment whatsoever up to this time
Dx?
Management? (3 steps)

Dx: Pyelonephritis

Management:
1. Hospitalization
2. IV antibiotics
3. Sonogram to make sure that there is no concomitant obstruction

(UTI should not happen in men or in children, and thus they should trigger looking for a cause. Women of reproductive age on the other hand, get cystitis all the time and they are treated with appropriate antibiotics without great fuss)

Management:
1. I.V. antibiotics
2. what should not be done is any more rectal exams or any vigorous prostatic massage...doing so could lead to septic shock

None

You receive a call from a patient at 3:00 AM. His regular urologist retired five years ago, and he has not sought a replacement. At about 11:00 PM last night, the patient injected himself with papaverine directly into the corpora, as he had been instructed to do for his chronic, organic impotence. He achieved a satisfactory erection and had intercourse, but the erection has not gone away and he still has it at this time
Dx?
Managment? (2 steps)

Dx: Priapism
(urological emergency)

Management:
1. Emergency Alpha Agonist (phenylephrine, epinephrine or terbutaline) into the corpora
2. Once the crisis is over, the patient has to be switched from papaverine to Prostaglandin E1, which in now the agent of choice to achieve erection because it is less likely to produce priapism
(Continued erection beyond four hours begins to damage the corpora)

None

You are called to the nursery to see an otherwise healthy looking newborn boy because he has not urinated in the first 24 hours of life. Physical exam shows a big distended urinary bladder.
Dx? (2 possible)
First step?
Diagnostic test?
Tx?

First step: Drain the bladder with a catheter
(it will pass through the valves)

Diagnostic test: Voiding cystourethrogram

Tx: Endoscopic Fulguration or Resection

None

A bunch of newborn boys are lined up in the nursery for you to do circumcisions. You notice that one of them has the urethral opening in the ventral side of his penis, about mid-way down the shaft.
Dx?
Next step?

Dx: Hypospadias

Next step: The point of the vignette is that you don’t do the circumcision. The foreskin may be needed later for reconstruction when the hypospadias is surgically corrected

None

A 7 year old child falls off a jungle gym and has minor abrasions and contusions. When checked by his pediatrician, a urinalysis shows microhematuria
Dx?
Diagnostic test?

Dx: Congenital Anomaly
(Hematuria from the trivial trauma in kids means congenital anomaly of some sort)

Diagnostic test: start with Sonogram (IVP may be needed later)

None

A 9 year old boy gives a history of three days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain and fever and chills for the past two days
Dx?
Management? (2 steps)

Dx: UTI
(Little boys are not supposed to get urinary tact infections. There is more than meets the eye here. A congenital anomaly has to be ruled out)

Management:
1. treat the infection
2. Sonogram right away to begin the work up

None

A mother brings her 6-year-old girl to you because “ she has failed miserably to get proper toilet training”. On questioning you find out that the little girl perceives normally the sensation of having to void, voids normally and at appropriate intervals, but also happens to be wet with urine all the time
Dx?
Management? (2 steps)
Tx?

Dx: (classic vignette) Low implantation of one ureter
(In little boys there would be no symptoms, because low implantation in boys is still above the sphincter, but in little girls the low ureter empties into the vagina and has no sphincter. The other ureter is normally implanted and accounts for her normal voiding pattern)
Management:
1. PE might show the abnormal ureteral opening
2. IVP

Tx: Surgical repair

None

A 16 year old boy sneaks out with his older brother’s friends, and goes on a beer-drinking binge for the first time in his life. He shortly thereafter develops colicky flank pain
Dx?
Diagnostic test?
Tx?

Dx: (classic) Ureteropelvic Junction Obstruction

Diagnostic test: Ultrasound

Tx: Surgical Repair will follow

None

A 62 year old male known to have normal renal function reports an episode of gross, painless hematuria. Further questioning determines that the patient has total hematuria rather than initial or terminal hematuria
Dx? (2 possible)
Diagnostic test?
If test is normal what is next step?

Dx: Either Infection or Tumor can produce hematuria.
(The blood is coming anywhere from the kidneys to the bladder, rather than the prostate or the urethra. In older patients without signs of infection cancer is the main concern)

Diagnostic test: IVP
(“gold standard-first study” in urology, except in postential obstruction, then Ultrasound)
If normal the next step: Cystoscopy

None

A 70 year old man is referred for evaluation because of a triad hematuria, flank pain and a flank mass. He also has hypercalcemia, erythrocytosis and elevated liver enzymes
Dx?
Diagnostic test? (2 steps)

Diagnostic test:
1. IVP first
2. CT scan next would be the standard sequence.
(In real life, if a urologist saw a patient with a palpable flank mass, he or she might go straight for the CT scan)

None

A 61 year old man presents with a history of hematuria. Intravenous pyelogram shows a renal mass, and sonogram shows it to be solid rather than cystic. CT scan shows a heterogenic, solid tumor.
Dx?

Dx: Renal cell carcinoma

None

A 55 year old, chronic smoker, reports three instances in the past two weeks when he has had painless, gross, total hematuria. In the past two months he has been treated twice for irritative voiding symptoms, but has not been febrile and urinary cultures have been negative
Dx?
Diagnostic test? (2 steps)

Dx: Bladder Cancer

Diagnostic test:
1. IVP
2. Cystogram
(With this very complete presentation some urologist would go for the cystoscopy first, but the standard sequence of IVP first and cystoscopy next is the only correct answer for an exam. An option both IVP and cystoscopy would be OK)

None

A 59 year old black man has a rock-hard, discrete, 1.5cm nodule felt in his prostate during a routine physical examination
Dx?
Diagnostic test?
Tx?

Dx: Cancer of the Prostate

Diagnostic test: Trans-rectal needle biopsy

Tx: Surgical resection after the extent of the disease has been established

None

An 82 year old gentleman who has congestive heart failure and chronic obstructive pulmonary disease is told by his primary care physician that his level of prostatic specific antigen (PSA) is abnormally high. The gentleman has seen ads in the paper for sonographic examinations of the prostate, and he has one done. The examination reveals a prostatic nodule, which on trans-rectal biopsy is proven to be carcinoma of the prostate. The man is completely asymptomatic as far as this cancer is concerned. He has not evidence of metastasis either.
Tx?

Tx: As a rule, asymptomatic prostatic cancer is not treated after age 75

(An example of technology running amock. This man should have never had the PSA in the first place, much less the sonogram and biopsy. After a certain age, most men get prostatic cancer...but die of something else)

None

A 25 year old man presents with a painless, hard testicular mass.
Dx?
Diagnostic test? (2)

Dx: Testicular cancer

Diagnostic test:
1. Pre-op Alpha-fetoprotein and Beta-HCG
2. Diagnosis is made by performing a radical orchiectomy by the inguinal route.
(That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definitive no-no)

None

A 25 year old man is found on a pre-employment chest X-Ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the past six months he has been losing weight for no obvious reason.
Dx?
Diagnostic test?
Tx? (2 steps)

Tx:
1. Removal of testicle
2. Chemotherapy
(The point of this vignette is that testicular cancer responds so well to chemotherapy, that treatment is undertaken regardless of the extent of the disease when first diagnosed)

None

A 60 year old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to, but can not. On physical exam his bladder is palpable half way up between the pubis and the umbilicus, and he has a big, boggy prostate gland without nodules. He gives a history that for several years now, he has been getting up four or five times a night to urinate. Because of a cold, two days ago he began taking anthihystaminics, using “nasal drops”, and drinking plenty of fluids.
Dx?
Management?
Tx? (2 possible)

Dx: Acute urinary retention, with underlying BPH

Management: Indwelling bladder catheter, to be left in for at least 3 days

Tx: long-term Alpha-blockers for symptomatic relief, or some form of Prostatic Resection

None

On the second post-operative day after surgery for repair of bilateral inguinal hernias, the patient reports that he “can not hold his urine”. Further questioning reveals that every few minutes he urinates a few cc’s of urine. On physical examination there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus.
Dx?
Management?

Dx: Acute Urinary Retention with Overflow Incontinence

Management: Indwelling bladder catheter

None

A 42 year old lady consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, seven years ago, she leaks a small amount of urine whenever she sneezes, laughs, gets out of a chair or lifts any heavy objects. She relates that she can hold her urine all through the night without any leaking whatsoever
Dx?
Tx?

Dx: Stress Incontinence

Tx: Surgical repair of the pelvic floor.

None

A 72 year old man who in previous years has passed a total of three urinary stones is now again having symptoms of ureteral colic. He has relatively mild pain that began six hours ago, and does not have much in the way of nausea and vomiting. X-Rays show a 3mm Ureteral stone just proximal to the ureterovesical junction
Management? (3 together)

(there is still a role for watching and waiting. This man is a good example: small stone, almost at the bladder. Give him time, medication for pain, and plenty of fluids, and he will probably pass it)

None

A 54 year old lady has a severe ureteral colic. IVP shows a 7mm Ureteral stone at the ureteropelvic junction
Tx?

Tx: Shock-wave Lithotripsy

(whereas a 3mm stone has a 70% chance of passing, a 7mm stone only has a 5% probability of doing so. This one will have to be smashed and retrieved)

None

A 33 year old man has urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical exam the prostate is not warm, boggy or tender
Dx?
Management? (3 together)

A 72 year old man consults you with a history for that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis
Dx? (2 possible)
Diagnostic test?
Tx?

Dx: Pneumaturia due to a Fistula between the bowel and the bladder.
(Most commonly from sigmoid colon to dome of the bladder, due to diverticulitis)
or Sigmoid Cancer

Diagnostic test: CT scan
(Intuitively you would think that either cystoscopy, sigmoidoscopy or contrast studies would verify the diagnosis, but they seldom show anything in this case)

Tx: Surgery will be needed

None

A 32 year old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his wife, but he still gets nocturnal erections and can masturbate normally
Dx?
Management?

patient in a MVA arrives with an enlarging pupil and a decrease in the level of consciousness since he arrived in the ED. It is obvious he has an increase in ICP.
What is specifically causing the symptoms?

Uncal Herniation

A 20yo female has brief loss of consciousness following head injury. She presents to the ED awake but is amnestic to the event and keeps asking the same questions over and over again.
Dx?